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MEDI-CAL ELIGIBILITY PROCEDURES MANUAL

Artide 19 - S P E C K SERVlCES

19A - lNDMDUALS ON RESTRICTED SERVICE STATUS DUE TO PROGRAM ABUSE

1. Background

2. DDS ResponsibiMes

3. County Weffire Department Responsibilities

4. Persons Affected

5. County Preparation and Submission of MC 177 Forms

6. Issuance of Appropriate Mediial Card

195 - THIS SECTION HAS BEEN RmAOVED FROM ARTICLE 19 AND INCORPORATED INTO ARTICLE 4V, MINOR CONSENT MEDI-CAL SERVICES, EFFECTIVE OCTOBER 24.1 995

19C - LIMITED SEFWCES FOR MEDICALLY INDIGENT ADULTS IN SNFACF

1. Background

2. County Welfare Department ResponsibiBes

3. Retroactive Eligibility

4. Media l Identification Card

19D - HOME AND COMMUNITY-BASED WAIVER PROGRAMS . .

1. Background

Ill. Waiver Types

N. Description

V. General Processing

VI. Forms

MANUAL LETTER NO.: DATE: s@ 2 4 1997 PA- ARTICLE19,TC-1

MEDI-CAL ELIGIBILITY MANUAL _---------------------------------------------------

19A - INDIVIDUALS ON RESTRICTED SERVICE STATUS DUE TO PROGRAM ABUSE

1. BACKGROUND

The Department of Health Services (DHS) has developed procedures t o ident i fy and resolve Medi-Cal program abuse by beneficiaries. Benefi- c i a r i e s who seek out and repeatedly obtain unnecessary services a r e

. issued special Hgdi-Cal identification cards t o not i fy providers that prior authorization is required for cer ta in services. Limftations on the beneficiaries' Medi-Cal coverage w i l l remain ia force for a m i n h m of one year anless altered by DES or a s t a t e hearing decision.

The DHS:

a. Ident i f ies beneficiaries t o be put on res t r ic ted s ta tus through reviev of beneficiary Mi-Cal service his tor ies . This involves a computerized selection process and a professional medical case review f o r selected patients.

b, Prepares and sends Notices of Action (MC 1705) t o the beneficiary a t least ten days before the res t r ic ted service status becomes effective,

c. Furnishes a copy of the written Notice of Action of the bene- f i c i a r i e s ' res t r ic ted service status t o the county pr ior t o the f i r s t of the manth i n which the restriction becomes effective.

d. Issues Mi-Cal identification cards t o the beneficiary vith. "restricted service" notations on the card, Currently, these messages are:

(I) Restricted Drugs, coded %I",

(2) Restricted Scheduled Drugs, coded "R5".

(3) Restricted H.D. V i s i t s , coded "R11".

(4) Restricted I)Ngs/H.D,, coded "R12".

nrrmraL LETTER NO. 81 ( 8 / 8 / 8 5 ) 19A-1 ----------------------------------------------------

MEDI-CAL ELtGlBl LlTY MANUAL _-_------------------------------------------------- I

(5) Restricted t o Primary H-D., coded "R14".

(6) Restricted t o P r i m a r y K,D./Drugs, coded "RlS*'.

e. R w i d e s each responsible county v i t h a monthly report of all individuals, including Supplemental Security IncmeIState Supple- mentary Payment (SSIISSP), vho a r e on r e s t r i c t ed service s ta tus .

f . Reviews.and, i f appropriate, authorizes a l l Iledi-Cal drug and/or I4.D.. visit requests f o r the beneficiary. (Prwiders have been informed by provider bu l l e t i n t h a t p r io r departmental approval is required by . the spec ia l coding indicated on tbe Mi-Cal ident i f i - cation cards. )

The c-ty welfare department is responsible for:

a. Beferring t o the monthly l i s t i n g (Lfmited Service Status Register (LSSR)) issued by DBS when processing requests fo r replacement1 supplemental Wgdi-Cal cards f o r SSI/SSP beneficiaries, and fo r all other Mi-Cal benefic iar ies i n the event of the WEDS system befog inoperational.

b- Accepting and forwarding requests for s t a t e hearing from persons vho uant t o appeal t h e i r r e s t r i c t ed s e m i c e status. Restricted service benefic iar ies m y request a state hearing within 90 days of t he initial ac t ion by DHS. Restricted s e m i c e status shall not be lifted because of the hear* request.

Restricted serPice benef ic iar ies may include any Medi-Cal beneficiary. I f a member of a multiperson &di-Cal Family Budget Unit (KFBU) is put on r e s t r i c t ed s e m c e s t a tu s , t h i s . u i l l n o t a f f e c t the s t a tu s of the other family members of the MFBU,

Counties need not make any special notations on the MC 177 forms of persons on r e s t r i c t ed se lv ice status in order t o have the special res t r ic ted serpice Mi-Cal card generated. %put fram DEB i s stored i n the WEDS computer f i l e which is used t o generate share-of-cost Mi-Cal cards-

MEDI-CAL ELiGIBlLlN MANUAL ----------------------------------------------------

I 19C -- LPLITED SERVICES FOR HEDICALLY INDIGERT

ADULTS IN SHFfICF

AB 799 (1982)- as modified by SB 2012 (1982) , mandated the State t o discontinue the medically indigent adult (MIA) category, with a feu exceptions, from the Medi-Cal program and t o transfer responsibility f o r the health care of those persans t o the counties effect ive January 1, 1983.

One of the exceptions t o tLe discantfnned :HIBs .is the category of MBs r e s u i n g 'in a skil led ssursiag f a c i l i t y (SHP) or intermediate care f a c i l i t y (ICF) who are identified by the Aid Code 53. Uhile a M I A i s a resident of an SHFfICF, heishe is entitled t o all benefits normally cwered by Mi-Cal. However, should that HIA beneficiary becane an inpatient at an acute care hospital, any sexvice rendered during that hospital stay w i l l not be cwered by the Medi-Cal program.

2. COUNTY WELFARE DEPAXDBNT RESPOlQSIBILITY

If an MIA beneficiary in an SHFfICF (Aid Code 53) becomes an inpatient a t an acute care f a c i l i t y , the mi-Cal program w i l l deny payment for any acute care hospital semices. Therefore, an evaluation or referral must be in i t i a t ed by the county welfare department o r other responsible agency t o determine possible e l i g i b i l i t y for connty medical assistance f o r tbose senrices not cwered under the Mi-Cal program.

An KIB beneficiary map have conmirent did Code 53 Medi-Cal cwerage and county medical assistance i n any month in which medical semdces were received in both an SHF/ICF and an acute care facility. In addition, should a d i sab i l i t y evaluation subsequently be approved, Aid Code 53 should be chsnged to a disabled aid code category effective with o r re t roact ive t o the d i sab i l i ty onset date.

EXAMPLE: I&. Sirtith, age 58, enters an SHF on February 7 as an MA. Mr. Smith fal ls on February 12, in jures himself, and is sent by ambu- lance t o the hospital f o r acute care. On February 15, Lfr. Smith i s returned to the SXF vhere he remains until his release on March 25.

Section 50251 NO- 81 (8 /8 /85 ) 19C-1 ----------------------------------------------------

MEDI-CAL ELIGIBILITY MANUAL --------------------------.------------------------- Benefits cwered by Hedi-Cal for February (assuming medical necessity i s established f o r all seroices) include any outpatient serpices recelved by lfr. k i t h during the month of Feb r~a ry ; . t he care he received in the SIP fram February 7 t o 12, February 15 t o 28, and Warch 1 t o 25; rrmbulance service; bed-hold a t the SW for a maxfmam of seven days during Mr. Smith's s t ay in acute care; and ;?my other care (e.g., pharmaceuticals, therapy) provided to Mr. Smith while he was i n the sm.

%mice8 received daring Mr. Smith's stay a t t he acute care hospi ta l are - not cwered by Wdi-Cal, including the s e d c e s of h i s physicians, podia t r i s t s , o r den t i s t s , even though Mr. Smith ranabed on Mi-Cal for the e n t i r e month of February. Evaluation f o r possible county medical assis tance should be done f o r those expenses incurred while Br. Smith was in t h e acute care fac i l i t y . Mr. Smith receives a March W-Cal card because of his continued residence i n the SW. Ee a l so receives an April Wedl-Cal card sbce there m s insuff ic ient time f o r the f ~ o o t y t o Issue a Notice of Action for discontinuance a f t e r h i s release from the SRF on Wrch 25.

?Ih map be e l i g i b l e for retroactive e l i g i b i l i t y i f both of the follow- fng conditiaas are met: I * The IEA resided i n an S#F/ICF for one day or more d u r h g the

month of application, I b. The resided in an SlE/ICP f o r one day or -re during the

re t roac t ive r~onth(8) for which Mi-Cal coverage is reqaested.

The re t roac t ive -th(s) are also coded with Aid Code 53, and the same serPices are cwered in the re t roact ive moath(s) a s i n the current month of e l i g i b i l i t y .

Aid W e 53 identifies a recipient as e l ig ib l e for Medi-Cal benef i t s lfmited t o senrice8 (outpatient o r inpatient) received while r e s i d h g i n an SNF/ICF. County welfare departments need not input any special code t o indicate e l i g i b i l i t y t o Lirmfted services. The Wed&-Cal identi- f i ca t ion card f o r bid Code 53 contains the following r e s t r i c t i o n message:

"Services t o acute hospital Inpatients are not cwered."

---------------------------------------------------- Section 50251 MANUAL LETTER HO. 85 ( 8/8/85) 19C-2


19D -- HOME AND COMMUNITY-BASED SERVICES (HCBS) WAIVERS

1. BACKGROUND

Section 191 5(c) of Title XIX of the Social Security Act, Section 14132(s) of the Welfare and Institutions Code, and Section 51346 of Title 22, California Code of Regulations permits states to request waivers of otherwise applicable federal law in order to provide certain services to persons at home or in the community as a cost neutral alternative to institutionalized health care, provided such non-institutional services meet the health and safety needs of the beneficiary. The goal is that the beneficiary will experience an enhanced and enriched quality of life if allowed to return home or to the community. The Department of Health Services (DHS) currently has six such waivers in effect.

Congress also authorized Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for eligible individuals under 21 years of age. EPSDT is a Medi-Cal benefit that requires that states provide medically necessary screening, vision, hearing, and dental services to Medi-Cal beneficiaries. One of the services that may be provided is licensed skilled nursing in the home. Therefore, Medi-Cal eligible children who are institutionalized will now be able to return home from institutionalization or those who are home can remain at home because they can receive additional medical services under the EPSDT program if certain criteria, including cost effectiveness, are met. It is no longer necessary that all children be in a waiver to receive expanded benefits if the child has a zero share of cost (SOC) under regular Medi-Cal incornelproperty rules. The Section 19-D procedures apply, however, if a waiver is required.

Assembly Bill (AB) 2779, Chapter 329, Statues of 1998, provides for the expansion of the Personal Care Services Program (PCSP) to the aged, blind or disabled medically needy. Prior to this, PCSP was offered to categorical and mandatory Medi-Cal coverage groups (e.g., Supplemental Security Income (SSI) recipients, Pickle beneficiaries, CalWORKs and Section 1931(b) recipients and pregnant women or children in the federal poverty level programs who meet the criteria for this program).

PCSP provides the following services:

Assistance to ambulate Bathing, oral hygiene, dressing, and grooming Care and assistance with prosthetic devices Bowel, bladder and menstrual care Repositioning, range of motion exercises and transfers Feeding and assurance of adequate fluid intake Respiration Paramedical services Assistance with self-administration of medications Ancillary services e.g., meal preparation, laundry, shopping and domestic services (these are only offered if other basic PCS are provided).

PCSP is a component of the In-Home Supportive Services (IHSS) program that also includes the IHSS-residual program, but unlike the IHSS-residual program, PCSP is a Medi-Cal benefit.

The IHSS-residual program and PCSP have some differing requirements. Unlike the IHSS-residual program, PCSP does not allow a parent of a minor child or a spouse to be the care provider. Even though the Medi-Cal Home and Community-Based Services (HCBS), Multipurpose Senior Services

SECTION NO.: 51346 MANUAL LETTER NO.: 291 DATE: 09/03/04 19D-1


Program (MSSP), and Department of Developmental Services (DDS) waivers (as described later in these procedures) disregard parental income and resources and also apply spousal impoverishment provisions, the IHSS-residual program does not. Therefore, a beneficiary who is ineligible for the IHSS-residual program solely because the IHSS-residual program counted parental income and resources or did not apply the spousal impoverishment provisions can receive PCSP if otherwise eligible.

II. OVERVIEW

If the applicant is in a waiver that uses special eligibility rules and helshe has been determined medically eligible or potentially medically eligible for a particular waiver, the agency responsible for the waiver will refer the applicant to the county contact for a Medi-Cal determination if helshe is not already receiving Medi-Cal with no monthly share of cost. Depending on the circumstances, this determination may be initiated while the applicant is still institutionalized or in a living arrangement different from the setting covered by the waiver.

Those persons who are applying for waivers that do not follow special eligibility rules, ( Acquired Immune Deficiency Syndrome Waiver) or persons who do not or would not have excess property or a monthly share of cost using regular Medi-Cal rules will not be referred to a special county waiver contact person. If these persons are not already receiving Medi-Cal, they may apply for Medi-Cal like any other applicant.

The following procedures describe the process counties are to follow in determining Medi-Cal eligibility.

A. Medi-Cal Eligibility Waiver Determination - Overview

There are several factors counties must consider such as the following:

1. Whether eligibility is to be based on regular Medi-Cal rules or special Medi-Cal rules depending on the type of waiver that the applicant will be in. Persons already Medi- Cal eligible without a share of cost may be eligible for some of these waivers without any special eligibility determination.

2. Whether the determination is based on anticipated circumstances or on actual circumstances (i.e., the current living arrangement is appropriate for the waiver and the referring agency already has determined it medically appropriate for the applicant to be in the waiver).

3. Whether the individual is a new applicant or a beneficiary with a change in circumstances.

New Applicant:

If the waiver applicant is not currently receiving Medi-Cal, helshe must complete an Application for Public Assistance and a Statement of Facts and meet all other requirements. The individual who is not currently receiving Medi-Cal will need an initial Medi-Cal eligibility determination based on hislher anticipated living situation. If the applicant has a parent or spouse in the home, the major concern is usually whether helshe will be eligible or have a high SOC due to parental or spousal income or excess property.

SECTION NO.: 51346 MANUAL LETTER NO.: 2 9 1 DATE:09/03/04 19D-2

-MEDI-CAL ELIGIBILITY PROCEDURES MANUAL

Therefore, individuals who are interested in leaving an institution and are applying for Medi-Cal and additional in-home services under a waiver need to know about their eligibility should they return home, e.g., whether they will be Medi-Cal eligible or have a SOC.

Beneficiary with a Change in Circumstances:

In some cases, the waiver applicant will be institutionalized and Medi-Cal eligible as an institutionalized individual prior to a referring agency contacting the CWD; however, depending on the waiver and circumstances, many persons may already be de-institutionalized prior to requesting an eligibility determination. Some may have never been institutionalized but have a high SOC or are in jeopardy of becoming institutionalized because their insurance is being terminated.

If the waiver applicant is currently receiving Medi-Cal-Only, the individual's move from an institutional setting to a non-institutional setting or from one community setting to another community setting generally will be treated by the county as a change in circumstances rather than a new application.

If an aged, blind, or disabled person is currently institutionalized and is already receiving Medi-Cal, helshe is likely to be in hislher own Medi-Cal family budget unit (MFBU) or may be receiving Supplemental Security Income (SSI) and automatic SSI-based Medi-Cal. A new eligibility determination based on a non-institutional living arrangement is required prior to the person being discharged either to the home of hislher spouse or parents or to a community setting to ensure continuing Medi-Cal eligibility and receipt of waiver services. NOTE: Some people may not lose Medi-Cal, may not have a share of cost or will continue on SSI and SSI-based Medi- cal upon returning home because the family incomelproperty is below the Medi-cal or SSI limit. Persons who continue to be or are eligible for SSI or qualify for a zero SOC Medi-Cal because the family incomelproperty is below the limit do not need to be determined using special eligibility rules for the HCBS, MSSP, or DDS waivers.

B. County Contact

Each county shall designate a waiver contact person. The county waiver contact person will receive the request for a Medi-Cal eligibility determination from the referring agency, coordinate the Medi-Cal eligibility determination, and answer questions about the program even though the actual determination may be made by other county staff. The contact for each county is attached to these procedures. It is important that applicants be directed to the county contacts because they understand how to process those waivers that disregard parental income and resources and apply spousal impoverishment rules. Once the county receives a referral, the county will determine Medi-Cal eligibility based on the criteria for the appropriate waiver including the living arrangement covered by the waiver.

I 111. WAIVERS TYPES

There are four types of waivers that are discussed in these Procedures. The first three may have special Medi-Cal eligibility determination requirements if the applicant is referred to the county by the designated agency. The last one currently follows regular eligibility rules. Note: The Model Waiver has been terminated and two new nursing facility waivers have been approved for persons eligible for

SECTION NO.: 51346 MANUAL LETTER NO.: 2 9 1 DATE109/03/04 19D-3


Level A and B and sub-acute care. The In-Home Medical Care waiver has been approved for persons eligible for acute hospital level of care. All three of these waivers are now referred to as the Medi-Cal In-Home Operations (IHO) Waivers.

A. Department of Developmental Services Home and Community-Based (DDS) Waiver B. Medi-Cal In-Home Operations (IHO) Waivers - Nursing Facility (NF) AIB Waiver, NF Subacute

Waiver and In-Home Medical Care Services (IHMC) Waiver C. Multipurpose Senior Services Program (MSSP) Waiver D. Acquired Immune Deficiency Syndrome (AIDS) Waiver

IV. DESCRIPTION AND PROCESSING

A. Department of Developmental Services (DDS) Home and Community-Based Services (HCBS) Waiver

1. Description

The DDS HCBS waiver offers services to individuals with developmental disabilities who live at home and meet the level of care criteria for certain intermediate care facilities for the developmentally disabled as defined in the California Health and Safety Code. Waiver eligibility will be determined by the regional centers, but counties are responsible for the Medi-Cal determination. Services provided include homemaker, home health aide services, habilitation, residential habilitation, day habilitation, prevocational services, supported employment services, environmental accessibility adaptations, skilled nursing, transportation, specialized medical equipment and supplies, respite care, chore services, personal emergency response systems, family training, adult residential care, adult foster care, assisted living, supported living services, vehicle adaptations, communication aides, crisis intervention, crisis intervention facility services, mobile crisis intervention, nutritional consultation, and behavior intervention services.

2. Referring Agency: Department of Developmental Services (DDS) - Regional Centers

DDS administers the DDS HCBS Waiver as delegated by DHS in accordance with the interagency agreement. DDS in turn contracts with twenty-one private, not for profit, regional centers which are responsible under state law for coordinating, providing, arranging or purchasing all services needed for eligible individuals with developmental disabilities in California. The regional center will determine whether the applicant is eligible to participate in the waiver program by reviewing the applicant's medical, social, and developmental care needs. Once waiver eligibility is determined, the regional center will refer himlher to the county for a Medi-Cal eligibility determination or redetermination via the Department of Developmental Services Waiver Referral form (DHS 7096). The regional center may act on the applicant's behalf if helshe cannot act for himlher self or the individual's financially responsible family member can act on hislher behalf. Counties may share ongoing eligibility information with the regional centers regardless of who acts on the client's behalf. See the attached list for the name and address titled "Contacts for Regional Centers*.

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3. Eligibility Requirements

The individual must be eligible for full scoDe benefits and meet all regular Medi-Cal eligibility rules such as California residency when determining eligibility for the waiver.

If the individual is eligible for Medi-Cal with no SOC, counties should not use the special waiver rules or report the individual to MEDS using the waiver aid codes. The county should contact the regional center and inform the contact that the waiver is not appropriate. However, if after a preliminary screening, it appears that the applicant will be property ineligible or has a SOC using parental or spousal income and property, the special rules below apply:

The applicant is treated as if helshe were institutionalized for purposes of the treatment of income and resources. If the applicant is an adult, spousal impoverishment rules apply. If the applicant is a child, parental income and resources are not considered even though the child lives in the home.

A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicap(s) or medical needs of the individual. Verification shall be by the physician's written statement of necessity.

The individual is in hislher own MFBU. If other family members wish to be aided, the individual is treated similar to those on public assistance (PA), e.g., the individual may be used to link other family members although the individual is not in the family's MFBU.

The waiver is limited to those who are eligible with or without a share of cost and are eligible for full benefits. A person residing in a nursing home under the state- only aid code of 53, a person in another limited scope aid code, or a person who does not have satisfactory immigration status is not eligible.

The county should use the most beneficial full scope Medi-Cal program to determine eligibility that is applicable to the applicant, e.g., the Aged and Disabled program, the Medically Needy program (MN), the Medically Indigent (MI) program, or the Percent programs. Eligibility is based on the waiver individual's own income and resources, including amounts remaining after spousal impoverishment rules are applied. The maintenance need is based on the income limit of the appropriate program used to determine eligibility rather than the $35 personal needs allowance.

For example: A child under age 19 who has a SOC in the MN or MI program or excess property may be eligible under the appropriate Percent program which disregards property using a family size of one. Helshe would then be reported to MEDS using the appropriate waiver aid code.

A disability determination is not required unless (1) eligibility is based on a Medi- cal program requiring that the individual be disabled, (2) the individual has no other basis for linkage or, (3) there would be an advantage if the applicant were disabled, e.g., income deductions available only to the disabled. This

SECTION NO.: 51346 MANUAL LETTER ~ 0 . : 2 9 1 ~ ~ ~ ~ f l 9 / 0 3 / 0 4 19D-5


determination of disability may be advantageous in the future when the child becomes an adult.

Aid codes for the DDS Waiver are:

6V No SOC 6W SOC

In some counties, persons in 6V may choose to be in a managed care plan. It is not mandatory unless the person resides in a county that has a County Organized Health System.

B. Medi-Cal In-Home Operations (IHO) Waiver

1. Description

These waivers are limited to persons who in the absence of the waiver program would otherwise require the nursing facility level A or B level of care for at least 365 consecutive days or sub-acute services for at least 180 consecutive days or acute hospital level of care (IHMC Waiver) for 90 consecutive days but who wish to live at home or in the community. Individuals under the age of 21 must be able to access a waiver service that is not covered under the EPSDT program. Inpatient status prior to the enrollment of waiver services is no longer required. Services provided include but are not limited to: case management, private duty nursing, home health aides, family training, waiver personal care (except for the IHMC Waiver) and adaptations to the home.

2. Referring Agency: DHS In-Home Operations (IHO)

The purpose of IHO is to ensure that necessary, appropriate, and quality medical and nursing services are authorized and provided in the home setting. IHO staff will facilitate the proposal documentation and development between each waiver participant and provider. This process allows for review of all issues related to the recipient level of care, evaluation of durable medical equipment, available waiver services, cost-effectiveness, and verification by IHO staff that the home environment is appropriate to meet the health and safety needs of the recipient. Final approvals of individual waiver requests are subject to review by a Medi-Cal Nurse Evaluator, Medi-Cal Medical Consultant, and other staff.

3. Referral Process

When the medical necessity determination has been completed, the county will receive a copy of the Medi-Cal HCBS Waiver Eligibility Notice. The county should contact the IHO eligibility liaison for the date of eligibility if the medical necessity determination has already been completed and the date is not stated. If the applicant is determined to be ineligible for any reason, the county should also inform the IHO eligibility liaison. For more information, counties may contact the following:

Department of Health Services In-Home Operations, Intake Unit Mail Station 4502, P.O. Box 997419 Sacramento, CA 95899-741 9 (916) 552-9105

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4. Eligibility Requirements

The Medi-Cal HCBS waiver has the same Medi-Cal eligibility rules as the DDS waiver. IHO will do some prescreening of income and property prior to referring the individual to the county.

The individual must meet all standard Medi-Cal eligibility rules such as California residency and cooperation when determining eligibility for the waiver.

If the individual is eligible for Medi-Cal with no SOC without using the special waiver rules, helshe is not eligible for the waiver. The county should contact IHO and inform the contact that the waiver is not appropriate. However, if after a preliminary screening, it appears that the applicant will be property ineligible or has a SOC using parental or spousal income and property, the special rules below apply:

The applicant is treated as if helshe were institutionalized for purposes of the treatment of income and resources. If the applicant is an adult, spousal impoverishment rules apply. If the applicant is a child, parental income and resources are not considered even though the child lives in the home.


The individual is in histher own MFBU. If other family members wish to be aided, the individual is treated similar to those on public assistance (PA), e.g., the individual may be used to link other family members although the individual is not in the family's MFBU.

The waiver is limited to those who are eligible with or without a share of cost and are eligible for full benefits. A person residing in a nursing home under the state- only aid code of 53, a person in another limited scope aid code, or a person who does not have satisfactory immigration status is not eligible.

The county should use the most beneficial full scope Medi-Cal program to determine eligibility that is applicable to the applicant, e.g., the Aged and Disabled program, the Medically Needy program (MN), the Medically Indigent (MI) program, or the Percent programs. Eligibility is based on the waiver individual's own income and resources, including amounts remaining after spousal impoverishment rules are applied. The maintenance need is based on the income limit of the appropriate program used to determine eligibility rather than the $35 personal needs allowance.

For example: A child under age 19 who has a SOC in the MN or MI program or excess property may be eligible under the appropriate Percent program which disregards property using a family size of one. Helshe would then be reported to MEDS using the appropriate waiver aid code.

- -

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A disability determination is not required unless (1) eligibility is based on a Medi- cal program requiring that the individual be disabled, (2) the individual has no other basis for linkage or, (3) there would be an advantage if the applicant were disabled, e.g., income deductions available only to the disabled. This determination of disability may be advantageous in the future when the child becomes an adult.

Aid Codes for the Medi-Cal IHO Waiver are:

6X IHO Waiver No SOC 6Y IHO Waiver SOC

In some counties, persons in 6X may choose to be in a managed care plan. It is not mandatory unless the person resides in a county that has a County Organized Health System.

C. Department of Aging Multipurpose Senior Services Program (MSSP) Waiver

1. Description

The MSSP waiver program is limited to the frail elderly who are over sixty-five years of age and receive Medi-Cal under an appropriate aid code. MSSP clients reside in their own homes within a particular service area. Potential clients are screened for eligibilityas to Level of Care (LOC) Determination and must be certifiable for placement in a nursing facility. Clients have to be appropriate for care management services and be able to be served within MSSP's cost limitations.

An amendment to this waiver was approved by the Centers for Medicare and Medicaid Services. Effective June 1, 2003, the new amendment will allow MSSP to bill Medi-Cal for transitional services that were provided during the last six months of a Medi-Cal individual's institutional stay. These services must be to support the de-institutionalization of a Medi-Cal individual and are billed once the individual leaves the institution. The new amendment also will now allow the county to determine eligibility using institutional deeming rules (spousal impoverishment) for a person who moves from the institution and returns home to hislher spouse or for a person who is already living at home with his or her spouse. The number of persons eligible under this provision is limited to five percent of the total waiver clients or about 816 persons state wide. The MSSP will be responsible for ensuring this limit is not exceeded.

MSSP provides interdisciplinary care management services including the coordination and use of existing community resources. Care managers initiate and oversee the process of assessments, care plan development, service arrangement, ongoing monitoring and reassessments of a client's needs. To arrange for services, care management staff must first explore support that might be available through family, friends, and the volunteer community. They then review existing publicly funded services and make direct referrals whenever possible. If needed services are not available through these resources, the care management team can authorize the purchase of some services from MSSP funds. Services that may be purchased under the waiver include: health care (skilled nursing); adult social day care; housing assistance; chore and personal care; respite; transportation; meal services; protective services; and special communication services. Referrals to the program come from a variety of sources including, but not limited to, local county agencies, social service and aging organizations, hospitals, home care agencies, and a variety of other community-based groups.



2. Referring Agency: California Department of Aging (CDA)

CDA has an interagency agreement with the Department of Health Services (DHS) to operate the MSSP Waiver. Within CDA, the MSSP Section of the Medi-Cal Services Branch is the unit responsible for reviewing and monitoring the program. CDA contracts with either public entities or private nonprofit agencies (MSSP sites) to run the program at the local level. CDA is responsible for oversight of these contracts. The local MSSP sites will determine the medical appropriateness of waiver coverage before referral to the county by reviewing the applicant's health and psychosocial needs and functional status. If appropriate, the MSSP site will refer him or her to the county for an eligibility determination or redetermination via the MSSP Waiver Referral form. Counties may share ongoing eligibility information with the local MSSP sites. Each site has identified a staff person to liaison with the county. Persons inquiring about the MSSP program should be referred to the appropriate agency on the Roster and contact list; however, only those persons who live within the boundaries of the sites may be eligible for MSSP services. There are some locations that are not within the boundaries of an agency at this time. Counties should phone the nearest contact person for more information.

3. Eligibility

Individuals who are Medi-Cal eligible using regular income and property rules (including spousal impoverishment if they are institutionalized and have community spouses) and who need MSSP services are evaluated by the MSSP program to determine whether they meet the MSSP criteria. These individuals may currently be in a nursing facility and wish to return to the home of their spouse or are already living at home with their spouse. Counties will not receive a waiver referral for individuals who are already eligible for Medi-Cal without an SOC and are currently receiving MSSP services unless they have a change in circumstances. In addition, some individuals are eligible for MSSP services who have an SOC (after spousal impoverishment rules are applied) if they also have a secondary Personal Care Services Program (PCSP) tracking aid code. (The SOC is certified as met at the beginning of the month based on the beneficiary's projected costs for his or her PCSP services.) If the person is not eligible for the PCSP secondary aid code, helshe is not eligible for the MSSP waiver and should not be reported to MEDS with only the MSSP SOC aid code.

When the county contact person receives an MSSP referral form for a married applicant or beneficiary and the county determines that the individual will be property ineligible or has an SOC using regular rules, the waiver allows institutional deeming rules to apply (similar to the special eligibility rules for the DDS and HCBS waivers). The Medi-Cal MSSP eligibility determination is as follows:

The applicantlbeneficiary is treated as if he or she were institutionalized for purposes of the treatment of income and resources.

Spousal impoverishment rules apply.


The MSSP individual is in hislher own Medi-Cal Family Budget Unit (MFBU). If other family members wish to be aided, the individual is treated similar to those on public

SECTION NO.: 51346 MANUAL LETTER NO.: 2 9 1 DATE: 09/03/04 19D-9


assistance, e.g., the individual may be used to link other family members although the individual is not in the family's MFBU.

w The MSSP individual must be eligible for fulr benefits with or without an SOC. NOTE: A person residing in a nursing home under the limited state-only Aid Code of 53, a person in another limited-scope aid code, or a person who does not have satisfactory immigration status is not eligible.

w The county should use the most beneficial full-scope Medi-Cal program to determine eligibility that is applicable to the applicant, e.g., Pickle, the Aged and Disabled program, the Medically Needy (MN) program. Eligibility is based on the individual's own income and resources, including amounts remaining after spousal impoverishment rules are applied.

Example A

John is a 70 year old applicant who is referred to the county by the MSSP site. He is living at home with his spouse. They have no minor children living in the home. The county determines that he is property eligible, but is not eligible for the Aged and Disabled Federal Poverty Level Program and would have an SOC as an MN person. The county then applies spousal impoverishment rules after certain deductions from his gross income. John may allocate the lesser of the maximum spousal income allocation to his spouse or up to her limit for the spouse at home. His monthly SOC is based on the remaining amount of his income. The county identifies him on the Medi-Cal Eligibility Data System with the appropriate new MSSP waiver aid code 1Y and the PCSP aid code of 1 F (after confirming that he is eligible for PCSP services and will meet his SOC at the beginning of each month using PCSP services).

Example B

Tom is 65 years old and currently eligible in the MN program with a monthly SOC of $1,000. The county receives a referral by the MSSP site. He is living at home with his spouse. There are no minor children in the home. The county applies spousal impoverishment rules and his SOC is reduced to zero (1X aid code).

Example C

Paul is 80 years old and referred to the county by the M S S P ' S ~ ~ ~ . He is living at home with his spouse and there are no minor children in the home. The county determines he is property ineligible for any Medi-Cal program and his own income is below the MN limit. The county then applies spousal impoverishment rules and finds him to be property eligible. Since his income is already below the MN limit, there is no need to allocate any of his income to the spouse (AX aid code).

4. New Aid Codes

Aid codes for individuals qualifying for the MSSP waiver under these special institutional deeming rules are:

1X MSSP No SOC I Y MSSP SOC (Must also be reported with IF)

SECTION NO.: 51346 MANUAL LETTER NO.: 2 9 1 DATE: 09/03/04 190-10


SECTION NO. : 51346 MANUAL LETTER NO.: 307 DATE: 12/10/09 19D-11.0

In some counties, persons in 1X may choose to be in a managed care plan. It is not mandatory unless the person resides in a county that has a County Organized Health System.

D. Assisted Living Waiver

Assisted living provides a viable alternative to long-term care for certain individuals because it allows individuals to live in the community while receiving many of the services that would be available in long-term care.

The Department of Health Care Services (DHCS) applied for and received federal approval from the federal Centers for Medicare and Medicaid Services (CMS) for an Assisted Living (AL) waiver. Approval was received in May 2005, with implementation of the waiver to run from January 1, 2006 through December 31, 2008.

During the January 2006-December 2008 period, the AL waiver operated as a pilot project with up to 1000 slots for enrollment. At the conclusion of this initial period, the pilot ended, but the waiver continues with federal approval for the waiver’s renewal, but with more counties participating. During the pilot, three counties (Sacramento, Los Angeles, and San Joaquin) had facilities that have agreed to participate in the pilot. This meant these facilities met the criteria for AL waiver participation and accepted the conditions for pilot participation.

As mentioned above, as the waiver progresses, facilities in other counties will be added and slots for enrollment will be increased. Counties are not responsible for monitoring enrollment numbers. The enrollment of individuals is the responsibility of the DHCS. If enrollment maximums have been reached, DHCS, rather than the counties, will inform the waiver applicant that the waiver’s enrollment is closed.

There will be instances when one county’s Medi-Cal resident will want to enroll in the AL waiver and will then move to an AL waiver provider site in another county. If the assisted living provider site is in another county, the current county of residence will determine whether an intercounty transfer is appropriate in addition to conducting any necessary Medi-Cal eligibility determinations for that resident. In some situations, an intercounty transfer is not needed, for example, when a married individual with a spouse on Medi-Cal will remain the responsibility of the county where the couple resided before one spouse’s move to LTC or assisted living.

Note: Any reference in these Procedures to “regular” Medi-Cal means that the county conducted an eligibility determination without applying any of the specific AL waiver rules.

1. Description

State law ( Welfare and Institutions Code 14132.26 as added by Assembly Bill 499 (Chapter 557 Statutes of 2000) created the Assisted Living Waiver Pilot Project



(ALWPP) to test the efficacy of assisted living as a Medi-Cal benefit and as an alternative to long-term nursing provider site placement.

The AL waiver will test the assisted living benefit in two settings.

▪ Residential care facilities for the elderly (RCFEs) and ▪ Publicly funded senior and/or disabled housing (PSH).

As described in paragraph five of item D above, individuals from any county may request enrollment into this waiver if they are willing to move to an AL waiver provider site in a another county. Therefore, any county may be required to make a Medi-Cal eligibility determination using AL waiver eligibility rules for a waiver applicant who resides in its county but who, if enrolled in the AL waiver, will move to another county where an AL waiver facility is located.

Regular Medi-Cal rules for determining which county is responsible for the eligibility determination apply. Generally, the county of responsibility is the county of residence of the individual. An individual does not have to initially reside in the county where the AL waiver provider site is located in order to request enrollment into the waiver, but the individual must be willing to move to that provider site if enrolled.

Medi-Cal eligible persons residing in an AL waiver provider site and enrolled into the AL waiver have the following characteristics:

Have full scope Medi-Cal eligibility without a Medi-Cal share-of-cost; Have enough disposable income as described in section 3a, step 4; Are aged or disabled; (Note: Blind applicants for the AL waiver will need to

be determined disabled to be part of this waiver.) Meet the nursing facility (NF) A or B level of care; and Are at least 21 years of age.

A person residing in a nursing facility under the state-only aid code 53, a person in another limited scope aid code, an individual who is limited scope due to alien status or due to failure to meet Deficit Reduction Act (DRA) requirements for verifying identity or citizenship cannot be in the waiver. Individuals also must meet all standard Medi-Cal eligibility requirements such as California residency and cooperation to be eligible for the waiver. Because an individual must have enough disposable income to provide for the cost of assisted living, all individuals in the AL waiver will have no share-of-cost Medi-Cal.

Eligibility is restricted to one Home and Community Based Service (HCBS) waiver at a time – concurrent enrollment in another HCBS waiver is not allowed.

The AL waiver benefits include:

Assisted living benefit as rendered by the RCFE setting



Assisted living benefit as rendered by a Medi-Cal licensed and certified home health agency in the PSH setting

Care coordination

2. Referring Agency:

The waiver is operated directly by the DHCS Long-Term Care Division, Monitoring and Oversight Section (MOS). The MOS provides the federal Centers for Medicare and Medicaid Services (CMS) with the assurances that necessary, appropriate, and quality care and other assisted living services are rendered as described in the wavier application. DHCS has also contracted with Care Coordinator Agencies (CCAs) to conduct some aspects of the AL waiver process. Current lists of CCAs are contained in the following website: www.californiaassistedliving.org. This website also contains information about the AL waiver.

3. Referral Process:

This section describes the referral process and although this section addresses AL waiver eligibility determinations, details about how these AL determinations are made are contained in Section 4, “Eligibility Requirements under the AL Waiver”. The referral form addressed below is contained in these Procedures.

A. Initial Enrollment Process

Step 1. Individuals who ask DHCS, a CCA, or AL waiver facilities about

enrolling in the AL waiver must be eligible for full scope Medi-Cal (with or without a share-of-cost) before any AL waiver assessments are made by DHCS or CCAs. For purposes of these Procedures, any reference to Medi-Cal or Medi-Cal eligibility assumes that the individual is or will be eligible for full scope Medi-Cal.

If an individual is already on Medi-Cal, the individual will be referred to a Care Coordinator Agency (CCA) who works on behalf of the DHCS by conducting level of care assessments. If an individual is not already a Medi-Cal beneficiary, he/she will be advised to apply for Medi-Cal at his/her county of residence and to then provide a CCA with the results of that determination. If a county becomes aware of an applicant or beneficiary who wants information about the AL waiver, the county should refer the individual to a CCA (see the website listed in paragraph 2 above for names of CCAs) and for an applicant, must continue to complete the regular Medi-Cal determination.

Step 2. CCAs conduct the level of care assessment for individuals who already

have had a Medi-Cal determination that resulted in either coverage for full scope Medi-Cal (with or without a share-of-cost) or if married, a denial due to excess property. No level of care assessments are made for any others who are ineligible for Medi-Cal or who have not yet had a regular Medi-Cal

http://www.californiaassistedliving.org/



determination. (Those married individuals who are ineligible due to excess property may turn out to be Medi-Cal eligible under the waiver once AL waiver rules are applied, so the level of care assessment is made.) Note: Such married individuals who would be Medi-Cal eligible once AL waiver rules are applied still must meet the AL Waiver requirement of being eligible for full scope no share of cost Medi-Cal. CCAs provide the results of the assessment to the MOS.

Step 3. MOS staff review the results of the level of care assessments.

(a) If the level of care criteria is not met for an individual, MOS informs the

individual that he/she is not eligible for the waiver. There is no referral to any county. The AL waiver process stops.

(b) If level of care criteria is met, MOS staff will review what kind of

Medi-Cal the individual has and takes the appropriate action described below.

(i) If the individual is eligible for regular Medi-Cal without a share-of-cost

based on receipt of SSI/SSP, MOS will enroll the individual directly into the waiver and inform the family or CCA to inform the Social Security Administration of the date of the individual’s entry into assisted living. There is no referral to any county.

(ii) If the individual is not on SSI/SSP, but is eligible for regular Medi-Cal

without a share-of-cost, MOS will continue with step 4.

(iii) If the individual is eligible for Medi-Cal with a share-of-cost or the individual is married and ineligible for Medi-Cal due to excess property, MOS will continue with step 4.

Step 4. Because the individual met the level of care criteria, he/she is potentially

eligible for AL waiver enrollment but he/she must be eligible for Medi-Cal as previously determined by the county and have enough disposable income to meet the costs of the AL Waiver. DHCS, not the counties, will make the determination as to whether an individual has enough disposable income to meet the costs of the AL waiver based on information such as whether the individual is on SSI/SSP, what the individual’s notice of action contains, and what information the county supplies on the Assisted Living Waiver Referral form, discussed in step 5 below. On May 1, 2009, this amount is $1086 which is the same amount as the SSI/SSP maximum total payment level for nonmedical board and care and includes a personal and incidental needs rate of $125. Note: This amount is subject to change, sometimes more frequently than annually. If there is such a change, it will be published via an All County Welfare Directors Letter as an update to the Pickle program handbook entitled, “SSI/SSP Section 16 Payment Standards”.



Frequently, DHCS/CCAs will refer individuals to the county for another eligibility determination that is to be based on the assumption that the individual is to be enrolled in the AL waiver and will move to an AL waiver facility. For example, there will be some individuals who under regular Medi-Cal have a share-of-cost but could become zero share-of-cost and have increased disposable income under a regular Medi-Cal determination if they were to move to a licensed board and care provider site and have the excess board and care or Petit v. Bonta board and care deduction applied. In addition, because the waiver has special eligibility provisions as explained later, some individuals who are married, but who have excess property, may be property eligible and thus eligible for Medi-Cal with or without a share-of-cost when these waiver provisions are applied in the eligibility determination. Therefore, individuals who meet the level of care criteria and who have a share-of-cost or if married, are ineligible due to excess property will be referred back to the county for an AL waiver eligibility determination. MOS will use the AL waiver referral form listed in item 31 Section 19 D VI that has been developed to request that the county welfare department’s waiver coordinator conduct another eligibility determination.

Step 5. The county will complete an AL waiver eligibility determination for the referred individual by determining his/her potential Medi-Cal eligibility/share-of-cost as if the individual were residing in a licensed board and care provider site. Depending on the circumstances of the case, the county may be using regular Medi-Cal rules with a board and care deduction or may be using AL waiver provisions. If the referred individual is already a Medi-Cal beneficiary, the county will need to redetermine the individual’s potential Medi-Cal eligibility/share-of-cost as if he/she were residing in a licensed board and care provider site unless the county already made a determination based on this living arrangement. See “Eligibility Requirements under the AL Waiver” below for detailed instructions on making this determination under AL waiver rules.

The county shall complete the section of the AL waiver referral form dealing with potential Medi-Cal eligibility/share-of-cost and return it to the DHCS MOS by mail, fax or email.

Important: Because MOS will need to determine whether an individual has sufficient disposable income to enroll in the AL waiver, the county must include the net nonexempt income calculation on the referral form.

Step 6. If the individual would be eligible for Medi-Cal based on enrollment into

the AL waiver, MOS will again determine whether the individual has sufficient disposable income to be enrolled into the waiver based on the county’s no share-of-cost/share-of-cost determination. If the individual is ineligible due to excess



property even after AL waiver rules are applied, MOS will not enroll the individual because he/she is not Medi-Cal eligible.

(a). If MOS determines that the individual is to be enrolled in the waiver, the

MOS and the individual will determine the date of the individual’s enrollment and when he/she will enter an AL waiver provider site. MOS will provide this information to the county via the referral form. The county will make any needed changes to eligibility based on this information, will report any eligibility changes as of the first of the month of residence in the AL provider site, and will issue an appropriate AL waiver approval notice of action, e.g., if there are changes to the individual’s current Medi-Cal eligibility that was determined under regular Medi-Cal rules.

(b). If MOS determines that the individual is not going to be enrolled in the AL

waiver, MOS will inform the individual and will also provide the county with the reason. If the reason is based on a county determination of ineligibility due to excess property or insufficient disposable income based on the county’s determination of net nonexempt income, the county must provide a notice of action stating that the individual is not eligible for the AL waiver and must include the income/property determination as appropriate, even if there are no changes to the individual’s current regular Medi-Cal eligibility. Please see Section 6 Notices of Action for more information.

B. Ongoing process

If an individual’s enrollment in the AL waiver is to end, the MOS will send this information to the county via the referral form. The county will need to redetermine Medi-Cal for the individual without applying waiver provisions. The county may also need to determine whether the individual will remain living in an assisted living provider site in making this determination.

If, at any time, the county determines that an individual’s eligibility has changed, the county must provide this information to MOS via the referral form. For example, if an individual in the waiver has benefits reduced from full scope to limited scope due to DRA requirements, the county must notify MOS via the referral form of this change. MOS will inform the individual that he/she is no longer eligible for the waiver.

4. Eligibility Requirements under AL Waiver rules

At this point in the process, the county should already have completed a regular Medi-Cal determination of ineligibility or eligibility with or without a share-of-cost. The purpose of a new eligibility determination is to see whether an individual who is likely to enroll in the AL waiver and who has a share-of-cost or if married is ineligible due to excess property under regular Medi-Cal would be



eligible for Medi-Cal without a share-of-cost based on potential enrollment into the AL waiver and a move to an AL waiver provider site.

Either one or two eligibility determinations will have to be made. That is, first using the hierarchy applicable in determining eligibility for regular Medi-Cal, the county shall determine whether the individual is eligible for a no share-of-cost full scope Medi-Cal program using regular Medi-Cal rules with the assumption that the individual will be living in an AL waiver provider site. At this stage of the eligibility determination, the potential waiver individual is not considered institutionalized nor do spousal impoverishment rules apply if he/she is married. If there is no share-of-cost eligibility, the county will report the waiver individual in that program’s aid code as of the first of the month in which he/she moves to the AL waiver provider site. Then, if there is no eligibility for a no share-of-cost program using regular Medi-Cal rules, the county will redetermine eligibility using the AL waiver rules described below as appropriate.

The following AL waiver provisions apply in this AL eligibility determination.

(a) The applicant is treated as if he/she were institutionalized for purposes of

deeming and determining the amount of income and property the waiver applicant has. This means the following:

1. The individual is in his/her own MFBU. If other family members wish

to be aided, the waiver individual is still treated similarly to a family member not living in the home.

2. Only the individual’s own income and property are used to determine

his/her financial eligibility after the methodology specified in (b) and (c) below is applied.

(b) Income methodology when applying institutional and spousal

impoverishment rules.

If the waiver individual is married, “name on the check” rule applies. That is, the owner of the income is the one named as its recipient. Community income is equally divided between the spouses. There is no deeming of income from the non-waiver spouse to the waiver spouse.

(i) Apply the standard deductions applicable to an aged or disabled

individual such as the $20 any income deduction. (ii) Deduct the greater of (1) the amount of unavailable income pursuant to

Title 22, Section 50515(a)(3) referred to as the “excess board and care deduction”) or (2) the $315 Petit v. Bonta deduction for personal care services.

Two Important Factors:



Background: According to Section 50515(a)(3), unavailable income includes that portion of monthly income of a medically needy person residing in a licensed board and care facility which is both: (A) Paid to the facility for residential care and support and (B) In excess of the appropriate maintenance need level in accordance with in Section 50603. The AL eligibility determination at this point is only a potential determination – what would happen if an individual were enrolled in the AL waiver and moved to an AL facility. There are two issues. First, no amount has actually been paid to the facility yet and secondly, some individuals are having their potential eligibility determined under programs other than the Medically Needy program. Therefore, the following provisions are to be used when applying Section 50515(a)(3).

The amount to be used as the amount paid to the licensed board and care

facility is the AL facility rate as determined as follows.

The SSI/SSP maximum total payment for nonmedical board and care is contained in Section 16-Payment Standards in the Pickle Handbook.

Although the SSI/SSP maximum total payment level for nonmedical board and care is used by DHCS to determine whether an individual has enough disposable income to be enrolled in the AL waiver, this amount contains a personal and incidental needs rate. (For example, on May 1, 2009, the nonmedical board and care rate is $1086 and the personal and incidental needs rate ranges from a minimum of $125 to a maximum of $220.

The personal and incidental needs rate is retained by the individual and is not paid to the facility and is not included in determining the excess board and care deduction. However, at this point in the income determination, it is not known whether the individual will retain the minimum or maximum personal and incidental needs rate. Therefore, for ease of administration, counties are to assume the waiver individual is retaining only the minimum personal and incidental needs allowance. For example, on May 1, 2009, the counties would assume the individual will retain $125 for personal needs and incidentals.

AL facility rate defined: The difference between the SSI/SSP nonmedical board and care payment level and the minimum personal and incidental needs rate is defined for purposes of the AL waiver as the AL facility rate. Therefore, as of May 1, 2009, the AL facility rate to be used is $ 961 ($1086 - $125).

The deduction specified in Section 50515(a)(3) also applies (if it is

greater than the Petit deduction) when determining income eligibility for the Aged and Disabled FPL program. In that situation, the excess board and care deduction would be the difference between the AL waiver



facility rate and the effective income standard for one for the A&D FPL program (the greater of 100 percent of the FPL plus $230 or the SSI/SSP payment standard).

(iii) Apply any applicable earned income deductions such as the $65

and ½. (iv) Deduct any health insurance premium payments. (v) Deduct court ordered child support or spousal support. (vi) Apply any deductions or disregards applicable to the specific

program for which the individual is being evaluated, for example, the $230 disregard applicable in the Aged and Disabled FPL program. Note that this $230 deduction is not applicable in the situation where the county is evaluating the individual for any program other than the Aged and Disabled FPL program.

(vii) Deduct the regular income standard/maintenance need income level for the program for which the individual is being evaluated, (for example, on April 1, 2009, the income limit for the Aged and Disabled FPL program is $1133 (100 percent of the FPL plus the $230 standard disregard because it is greater than the SSI/SSP payment level for one.

(viii) Deduct the amount pursuant to the spousal impoverishment provision for allocating income to the community spouse or family member if applicable. For example, the waiver individual may allocate the maximum spousal income allocation to the spouse up to the limit for the spouse at home or may allocate a lesser amount.

If there is no remaining income, the individual is eligible for no share-of-cost Medi-Cal under AL waiver provisions and the individual would be reported in aid code 14 or 64 when the individual is enrolled in the AL waiver and enters an AL waiver facility.

(c) Property methodology when applying institutional and spousal

impoverishment rules

There are no changes from the provisions applied in a regular Medi-Cal determination except that spousal impoverishment provisions for property apply. The property of both spouses is treated just as if the waiver applicant were an institutionalized individual. The non waiver spouse may retain the community spouse resource allowance which is the greatest of the following:

the standard amount an amount established by fair hearing an amount established by court order.



The spouse deemed to be institutionalized can retain another $2000 of countable property. The full spousal impoverishment process is contained in ACWDL 90-01, except that the transfer of property penalties contained in that letter do not apply to individuals in the AL waiver.

(d) Disability Determination

As stated in the description of the waiver, an individual must either be aged or disabled to be in this waiver. If an individual requests a disability determination or needs such a determination for waiver eligibility, counties must follow all applicable regulations and procedures to ensure that such a disability determination is made. An individual determined to be presumptively disabled is disabled.

5. Aid Codes

Aid codes are being developed for this AL waiver to more easily identify AL waiver enrollees. During the AL waiver pilot, an individual who was eligible for no share-of-cost Medi-Cal by using AL waiver rules and was enrolled in the waiver was placed in aid code 14 if aged or 64 if disabled. Until the new aid codes are operational, counties shall report an individual who is eligible for no share-of-cost Medi-Cal by using AL waiver rules and is enrolled in the waiver in aid code 14 if aged or 64 if disabled.

6. Notices of Action

As described above, individuals wishing to enroll into the AL waiver must have had a Medi-Cal determination using regular Medi-Cal rules before being evaluated for enrollment into the AL waiver by DHCS. Such individuals would have then already received a regular Medi-Cal notice of action.

If an individual is to move into an AL waiver provider site and is then eligible using regular Medi-Cal rules, the county shall use a regular Medi-Cal notice of action.

However, if eligibility/ineligibility is based on use of special AL rules such as institutional deeming rules and spousal impoverishment provisions, two new notices of action have been developed that counties must use depending upon the circumstances of the case.

These notices are listed in items 28 and 29 in 19 D VI Forms, Notices and Brochures. In addition, we have developed a third notice in the unlikely event that the county is determining initial Medi-Cal eligibility under AL waiver rules. Copies of the English version of these three notices are on pages 19 D 57.1, 19 D 57.2, and 19 D 57.3. Translations in the threshold languages (as they become available) will be on the DHCS website at http://www.dhcs.ca.gov/formsandpubs/forms/Pages/MCEBForms.aspx.

http://www.dhcs.ca.gov/formsandpubs/forms/Pages/MCEBForms.aspx



Note that individuals who do not meet screening criteria, level of care criteria, or do not have sufficient disposable income to meet the costs of assisted living as determined by DHCS will be informed by the DHCS that they are not being enrolled into the waiver.

7. Examples

Example 1.

An aged/disabled individual has just moved to an assisted living provider site that is also a licensed board and care provider site. The facility is not an AL waiver facility and the facility costs are $900. The individual wants to apply for the AL waiver because of the waiver services. He contacts a Care Coordinator Agency (CCA) that tells him he must first apply for Medi-Cal. He contacts his county department of social services for a regular Medi-Cal determination. The individual has never been on SSI so there is no Pickle determination. He has no property. The county reviews his eligibility for the A&D FPL program. The county makes the following determination based on his gross income of $2281. Assume the effective income limit for the A&D FPL program is $1133. Assume that the AL facility rate is $ 961.

1. The county first determines regular eligibility for the A&D FPL program while the individual is in the assisted living (licensed board and care) provider site. Assume the effective income limit for the A&D FPL program is $1133. The excess board and care deduction pursuant to Title 22 Section 50515(a)(3) is $0 ($ 900 facility rate - $1133). The $315 Petit deduction is used in the A&D FPL income determination because it is the larger amount. Note: Although the A&D FPL program does not apply to an individual in long term care, the waiver individual is not actually in LTC so he/she may be evaluated for the A&D FPL program.

Applicant’s income $ 2281 Any income deduction - 20 $ 2261 Disregard unavailable income pursuant to Petit - 315 Net nonexempt income $ 1946 The applicant is ineligible for the A&D FPL program under regular rules because his/her net nonexempt income exceeds $1133. Assume he is ineligible for all other no share-of-cost Medi-Cal programs but would have a share-of-cost under regular Medi-Cal rules. The county issues a regular Notice of Action that the individual provides to the CCA. The CCA sends the referral notice to the county and requests an eligibility determination as if the individual were enrolled in the AL waiver and moved to an AL facility site.



2. The county then considers his eligibility as if he were in the AL waiver. Assume the AL facility rate is $961 ($1086 - $125, the difference between the SSI/SSP nonmedical board and care payment level and the minimum personal and incidental needs rate). The county first considers his eligibility for no share-of-cost programs, but he is ineligible. The county then considers him for the ABD-Medically Needy (ABD-MN) program as if he were in an AL facility. Note that the Petit deduction of $315 is less than the $361 deduction for unavailable income pursuant to Title 22, Section 50515(a)(3) ($961 AL waiver facility rate-$600 MNIL). Applicant’s income $ 2281Any income deduction - 20 $ 2261Disregard for unavailable income - 361(Note that this income makes him ineligible for any no cost program $ 1900Maintenance Need Income Level - 600Share-of-cost $ 1300

Because the individual is unmarried, there are no AL waiver income provisions that would reduce his income and share-of-cost. The county returns the AL referral form to DHCS/CCA with this information. The CCA will screen the individual for the AL Waiver. We do not consider the share-of-cost amount available to meet costs of assisted living under the AL waiver (the SSI/SSP nonmedical board and care rate). This means that the individual has only $981 disposable income ($20 + $361 + $600) disposable income which is less than the SSI/SSP nonmedical board and care costs. The CCA/MOS staff informs the individual that he/she does not sufficient disposable income to meet the costs of assisted living under the waiver and that he/she will not be enrolled. The CCA/MOS staff also returns the referral form to the county with this information. The county sends the individual the notice of action “Denial of Enrollment in the Assisted Living Waiver and/or Medi-Cal”.

Example 2.

An aged/disabled husband wants to move from the home he and his wife are living in, to live in an assisted living provider site that is also a licensed board and care provider site. His spouse will remain in their home. Neither is on Medi-Cal, but the husband wants to apply for the AL waiver and he contacts a CCA. The wife does not want Medi-Cal. The CCA tells the husband to apply for Medi-Cal and provide them the results.

The husband applies for Medi-Cal and the county makes the determination based on the following. Assume the husband has $871 from Social Security and his wife has $1509 in her name. The couple receives $820 income in both of their names. The county determines that the $820 is from community property and that the originating documentation does not specify an amount for each. Therefore, the county divides the $820 equally between the spouses so each is considered to



have $410. The husband has $1281 of income and the wife has $1919. They have $111,560 in community property. The husband pays a $100 monthly conservator fee that meets Medi-Cal rules for such a deduction and an $81 health insurance premium.

The county determines that he has never been on SSI/SSP so he would never be eligible for Pickle. Furthermore, he is not eligible for any Medi-Cal program due to excess property. The county sends him a denial notice of action. The husband provides his notice of action to the CCA. The CCA screens the individual. Assume he meets the screening criteria so that the CCA sends the AL waiver referral form to the county asking for an eligibility determination using AL waiver rules as appropriate. Assume the AL waiver facility rate is $961.

The county then completes the husband’s income and property determination using AL waiver rules based on the supposition that the husband will be moving to a licensed AL waiver board and care provider site. Note that if there had been eligibility using regular rules, the county would not have needed to apply AL waiver spousal impoverishment. Assume the effective A&D FPL income standard for one is $1133. The excess board and care deduction is $0 ($961 AL waiver facility rate - $1133). Therefore, the income determination includes the $315 disregard pursuant to the Petit deduction because it is larger.

The husband is treated as if he were institutionalized for purposes of determining his own income and property so if the husband were treated as if he were in long-term care, there would be no income deemed from the spouse at home.

1. Income eligibility/share-of-cost determination

The county determines the husband’s income eligibility under AL waiver rules for the A&D FPL program. Note: Because the husband is treated as if he were institutionalized for determining his own income and there is no income deemed from the spouse, the AL waiver rules supersede the regular Medi-Cal rules and there is no deduction given for the maintenance need income level of the spouse as there would be under regular Medi-Cal rules. Assume the Minimum Monthly Maintenance Need Allowance (MMMNA) is $2739. The husband may allocate up to $820 to his wife ($2739 MMMNA - $1919, the wife’s income).

Waiver applicant husband’s income $ 1281Any income deduction - 20Unavailable income deducted pursuant to Petit - 315Amount deducted for conservator fee - 100Amount deducted for health insurance premium - 81Remainder $ 765Allocation to wife pursuant to spousal impoverishment - 765Net nonexempt income $ 0



The husband will meet the income requirement for the A&D FPL program using AL waiver rules once he moves to an AL waiver provider site because his income is less than $1133.

2. Property determination:

The county determines whether the husband meets the property limit of $2000 for the A&D FPL program applying the spousal impoverishment provision allowed under the terms of the AL waiver. The couple’s total property is $111,560. Assume the community spouse resource allowance is $109,560 and the husband transferred $109,560 to his wife by the end of the CSRA transfer period. His remaining property would be $2000 and he meets the property limit.

The husband meets both the A&D FPL income limit and the property

limit using AL waiver provisions. He therefore is eligible for the A&D FPL program and eligible for no share-of-cost full scope Medi-Cal using AL waiver rules. The county will return the AL referral form to the CCA with the income calculation and information that the husband will be eligible for Medi-Cal with no share-of-cost using AL waiver rules.

The CCA determines that the husband does not have sufficient income to pay for assisted living under the AL waiver. If he continues paying the $100 conservator fee and the $81 health insurance premium, he would have $1100 ($1281-$181), but if he pays the $765 MMMNA, he would have only $335. Assume the CCA discusses this with the husband and his family and the family agrees to pay the AL facility the difference between its AL facility rate and the amount the husband can pay the facility. (Note: The husband will continue to get the MMMNA spousal allocation deduction even if his wife is the one who agreed to use her allocation to pay the facility because we do not monitor how a community spouse uses her income including the allocation.) Assuming that the husband will be enrolled in the AL waiver, the CCA will inform the county of the husband’s enrollment into the AL waiver and his expected date of entry into assisted living. The county provides the husband with the notice of action, “Approval of Enrollment in Assisted Living Waiver and Initial Medi-Cal ”. The county will report his eligibility under aid code 64 for that month.

E. DHS Acquired Immune Deficiency Syndrome (AIDS) Waiver

1. Description

The AIDS Medi-Cal Waiver Program (MCWP) is limited to persons with a symptomatic Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS) with symptoms related to HIV disease who would otherwise require nursing facility or hospital level of care. Services provided include case management, skilled nursing, attendant care, psycho-social counseling, non-emergency medical transportation, homemaker services, specialized medical equipment and supplies, minor physical adaptations to the



home, a limited supplement for infants and children in foster care, nutritional supplements/home delivered meals. The Office of AIDS contracts with MCWP projects to implement the program at the local level and provide interdisciplinary comprehensive nurse and social work case management services. The case managers at these local Waiver agencies initiate and oversee the process of assignments, care plan development, service arrangement, ongoing monitoring and reassessments of a client’s needs. To arrange for services, case management staff must first explore support that might be available through family, friends, and the volunteer community. They then review existing publicly funded services and make direct referrals whenever possible. If needed services are not available through these resources, the case manager can authorize the purchase of services from MCWP funds. Referrals to the MCWP come from a variety of sources including, but not limited to, local county agencies, social service and aging organizations, hospitals, home care agencies, and a variety of other community-based groups.

2. Referring Agency: Local AIDS MCWP projects

MCWP projects will refer applicants to the county for determination of Medi-Cal eligibility. An individual must be a Medi-Cal beneficiary prior to enrollment in the AIDS MCWP.

3. Eligibility The individual must be eligible for full scope benefits and meet all regular

Medi-Cal eligibility. No special Medi-Cal income, property or institutional deeming rules apply. If the applicant is living in the home, he/she is not in a separate MFBU from his/her parent/spouse.

V. GENERAL PROCESSING INFORMATION

A. Notices of Action (NOA)

All waiver applicants should receive a NOA approving or denying Medi-Cal eligibility. The county will send a NOA to the applicant and a copy to the appropriate State referring agency, MSSP site or Regional Center. The MSSP, IHO, and DDS waiver applicants and beneficiaries have special NOAs. The MCWP projects also sends out a special NOA. Copies of these NOA’s are included in these procedures.

B. Beginning Date of Waiver Eligibility

The effective date of Medi-Cal coverage for applicants of a waiver where the waiver has special eligibility rules should be the date the following two requirements are met:



1. The referring agency determines that it is medically appropriate for the waiver applicant to be in that waiver, and

2. The county determines that the waiver applicant meets the Medi-Cal

eligibility requirements under that waiver.

Counties should contact IHO, the MSSP contact person, or the Regional Center to determine the effective date unless it is indicated on the referral form. NOTE: Retroactive eligibility rules as stated in Section 50710 of the California Code of Regulations remain in effect except for the MSSP Waiver.

C. There may be waiver persons requesting In-Home Supportive Services (IHSS). The IHSS residual component does not waive parental income and resources of parents or use spousal impoverishment rules; therefore, it is unlikely that the beneficiary will be eligible. Counties may refer these persons to the PCSP component of IHSS; however, a parent or spouse may not be the provider of services.

D. Annual Redetermination



The county shall redetermine eligibility as required by section 50189. Only information about the waiver beneficiary is required. Counties should check with IHO, the MSSP contact, or the referring Regional Center at the yearly determination to verify that the waiver beneficiary is still medically eligible for the waiver unless there is an agreement that the agency will notify the county if a beneficiary is no longer eligible for the waiver.

E. Medi-Cal Family Budget Unit (MFBU)

Persons in the MSSP, HCBS, and DDS waivers are in their own MFBU. Spousal Impoverishment rules apply. Since the waiver person is in his/her own MFBU, the maintenance need or income limit for the waiver person is based on a family size of one for the appropriate program rather than the $35 personal needs allowance. If there are multiple persons in the same household applying for these waivers, each person is in his/her own MFBU. If other family members are applying for or are receiving regular Medi-Cal, the IHO, MSSP, or DDS waiver applicant/beneficiary should be treated similar to public assistance (PA) recipients, e.g., they are not in the MFBU with other family members; however, they may be used to link other family members. Persons applying for the other waivers that do not use special eligibility rules are considered part of the household if they are determined to be living in the home; therefore, regular Medi-Cal MFBU rules apply. NOTE: if it is more beneficial for the person to be in the MFBU with the other family members, the waiver applicant may choose not to be in the waiver and to be determined under regular Medi-Cal rules. The county should notify the referring agency of the decision.

F. SSI Personal Needs Allowance (PNA) Effective June 1, 1990, federal law began allowing a former institutionalized SSI

child the same personal needs allowance (PNA) as an institutionalized SSI child as long as the non-institutionalized child is in a home and community-based waiver. Because the Social Security Administration (SSA) needs to confirm that such a child is in a waiver before the PNA can begin or that such child remains in a waiver for the PNA to continue, counties may be requested to verify such information at the time waiver coverage begins and then at the SSA redetermination. Since such information is confidential, counties must first have permission from the child’s parent or from another appropriate adult before releasing this information to SSA. The DHS 7071 form was developed to secure this parental consent and may be used to release this information to SSA.

Although DHS has developed a system to allow the waiver aid code to continue, counties should be aware that in some cases (depending on how SSA enters the information), when the waiver beneficiary begins receiving the PNA, MEDS will convert the waiver aid code to an aid code of 60. If this occurs and the waiver person is still living in the home and is not eligible for a regular SSI payment, counties should contact DHS so this may be corrected.



G. Quality Control

Counties should indicate that a special income and resource determination was used when determining eligibility for persons in the IHO, MSSP, and DDS waivers to prevent confusion when persons such as Quality Control review the file. A copy of the DDS or CDA referral form or IHO notice should also be in the file.

VI. FORMS, NOTICES, AND BROCHURES

1. Department of Developmental Services Waiver Referral Form (DHS 7096) 2. Spanish DDS Waiver Referral Form (DHS 7096 SP) 3. Medi-Cal Waiver Information and Authorization [formerly called the “SSI Payments

for Disabled Children Living at Home” (DHS 7071) 4. Approval Notice of Action for the DDS Waiver (MC 341) 5. Spanish Approval Notice of Action for the DDS Waiver (MC 341 SP) 6. Denial or Discontinuance Notice of Action for the DDS Waiver (MC 342) 7. Spanish Denial or Discontinuance Notice of Action for the DDS Waiver

(MC 342 SP) 8. Regional Center Contacts 9. Department of Developmental Services Brochure 10. IHO Waiver Medi-Cal Eligibility Notice for all Applicants Except Los Angeles

County (Number1) 11. IHO Waiver Medi-Cal Eligibility Notice for Los Angeles County Applicants

(Number 2) 12. IHO Waiver to inform a DDS Waiver Beneficiary of a Change to the HCBS Waiver

(Number 3) 13. Approval Notice of Action for the IHO Waiver (MC343) 14. Spanish Approval Notice of Action for the IHO Waiver (MC 343 SP) 15. Denial or Discontinuance Notice of Action for the IHO Waiver (MC 344) 16. Spanish Denial or Discontinuance Notice of Action for the IHO Waiver (MC 344 SP) 17. In-Home operations Brochures 18. AIDS Medi-Cal Waiver Program Notice of Action (MCWP2) 19. Spanish AIDS Medi-Cal Waiver Program Notice of Action (MCWP2 SP) 20. MSSP Site Roster 21. MSSP Contact Names 22. MSSP Approval Notice of Action (MC 365) 23. Spanish MSSP Approval Notice of Action (MC 365 SP) 24. MSSP Denial or Discontinuance of Benefits (MC 366) 25. Spanish MSSP Approval Notice of Action (MC 366 SP) 26. California Department of Aging Waiver Referral Form (MC 364)



27. County Waiver Contacts 28. Approval of Enrollment in Assisted Living Waiver with Medi-Cal Changes for

Beneficiary (MC 240) 29. Denial of Enrollment in Assisted Living Waiver and/or Medi-Cal (MC 242) 30. Approval of Enrollment in Assisted Living Waiver and Initial Medi-Cal (MC 241) 31. Assisted Living Waiver Referral Form


slate 01 ~ a b l m n m - ~ e ~ t h a M Human Sewres A p e 9 De~wrnenl 01 Healtn Servses --

DEPARTMENT OF DEVELOPMENTAL SERVICES

WAIVER REFERRAL

CALIFORNIA REGIONAL CENTER-Please complete this portion and forward to the appropriate County Waiver Contact Person.

Name of applcant

I I '

ParenVGuardian (it applicable)

Address (number, street)

I I

State City

STATUS

ZIP code

Telephone Social Secunty number

0 New Medi-Cal applicant. 0 Currently receives Medi-Cal with a share of cost. Reevaluate under special institutional deeming rules.

Date of birth

Address of parenVguaidlan (11 dlnerem)

LIVING ARRANGEMENT

State Ctty

0 The applicant is currently in an institution. Please determine Medi-Gal eligibility based on hislher anticipated return to the home.

ZfP code

- Anticipated date of discharge

0 The applicant is currently living in the home. IJ Other:

This is to certify that the individual named above has met the admission criteria for an intermediate care facility for the developmentally disabled as defined in the California Health and Safety Code, Chapter 2, Section 1250. Signature of Regional Center contact person

NOTE TO COUNTY: The eligibility determination waives parental and spousal income and resources even if the applicant lives i n the home. See Section 19D of the Medi-Cal Eligibi l i ty Procedures Manual. If the applicanubeneficiary is entitled to zero share of cost Medi-Cal under regular eligibility rules, no waiver is required.

r

Please send a copy of the Notice of Action to the Regional Center when the determination is completed.

White: County copy Yellow: Regional Center Copy

DHS 7096 (7199)

Telephone

Stale ( 1

ZIP code

Pnnted name of Reglonal Center contact person

Regional Center address (number, stret)


--

Xtle

City


Slate of CYifomtbHeYLh an6 Human Servhes Agency

ENV~O A PROGRAMAS ESPECIALES DEL DEPARTAMENTO QUE PROPORCIONA

SERVlClOS A PERSONAS CON INCAPACIDADES ADQUlRlDAS AL NACER 0

DURANTE EL DESARROLLO

CENTRO REGIONAL DE CALIFORNIA4or favor, Ilene esta parte y enviela a la persona encargada de programas especiales del condado.

Nombre deVde la sollcltante

Nuevo(a) solicitante de Medical. 0 Actualmente recibe M e d i a l con una parte del costo. Volver a evaluar conforme a reglas institucionales especiales consideradas.

D~reccldn (numero, calle)

Numero de Seguro Soclal

ARREGLOS DE VlVlENDA

Cbdigo postal Dlrecctbn del padrelrnadreAutor(a) legal (si es diferente)

0 Ellla solicitante vive actualmente en una instalaci6n. Por favor determine la elegibilidad de MediiCal basandose en su regreso previsto al hogar. Fecha prevista para que se le de de aka

0 EVla solicitante vive actualmente en el hogar.

Padre/Madrflutor(a) legal (51 es pectlnente) ( )

0 Otro:

C6dlgo postal Cludad

Cludad

Esto es para cerlificar que el individuo mencionado anferiormente ha cumplido con 10s requisites de ingreso a on centro de convalecencia para personas con incapacidades adquiridas a1 nacer o duranfe el desarrollo, seglin se define en la seccion 1250, capitulo 2, del C&go de

Enado

Estado

. . Seguridad y Salud de ~alifornia. Flrma de la persona encargada del Cenlro Regional

Fecha de naclmlento

> Nornbre en letra de molde de la persona encargada del Centro Regional 1 Titulo I Tel6fono

Telblono

NOTA AL CONDADO: La determinaci6n de elegibilidad posterga el ingreso y 10s recursos paternoslmaternos Y conyugales, aun si ellla solicitante vive en ei hogar. Vea la seccion 19D del Manual de Procedirnientos de Elegibilidad de Medi-Cal. Si ellla solicitantelbeneficiario(a) tiene derecho a Medi-Cal sin parte del costo conforme a las reglaS regulares de elegibilidad, no se requiere ninguna postergaci6n.

Direrribn del Centro Reg~onal (nurnero, calle)

Por favor, envie una copia de la Notificacion de Accion al Centro Regional cuando se complete la deterrninacion.

White: County copy Yellow: Regional Center Copy

Ciudad

DHS 7096 (SP) VR9)

SECTION NO.: 51346 MANUAL LETTER NO.: 29 1 D A T E : o ~ / o ~ / o ~ 19D-16

( ) Estado . C6digo postal


S w e a f CaMwrubHe l lh wJ Hvrnan SMI1 A g e w hcairnenl 01 Health Sew-

MEDI-CAL WAIVER INFORMATION AND

AUTHORIZATION

COUNTY USE ONLY yj ParenUGuardian: If your child was receiving Supplemental Security Income (SSI) payments while in an institution. Is under 18 years of age, is now receiving Medi-Cal benefits, is now living at home, and is currently in a home- and community-based waiver program, helshe may be eligible to receive a monthly SSI personal needs payment. Please complete this portion of the form and forward to the County Waiver Person if your child is in a MedCCal In-Home Operations or Developmental Services Waiver. For other waivers, forward this form to the State of California, Department of Health Sewices, Medi-Cal Eligibility Branch. Mail Station 4608. P.O. Box 997413. Sacramento. CA 95899-7413. After the County or State has verified !hat your child is i n a Medi-Cal waiver, submil this form to the Social Security Administration for a determination. SSA will continue to contact the County or State each year prior to continuing the personal needs payment.

I, the parent or guardian of the above child, authorize the County of or the State of California to disclose to the Social Security Administration information about the above child's status in the Medical home- and community-based waiver program.

ZIP mde

- -

COUNTY DEPARTMENT OF SOCIAL SERVICES: Please verify that the above child is currently receiving Medi-Cal benefits at home and is receiving services under the Model or DDS waiver.

Stale Mueu (numea. % r M )

Address of wenuguadlan (11 dtflaenl)

I certify that the above named child is receiving Medi-Cal benefits under one of the following home- and community-based waivers:

CW

Stale Ctly

0 Medi-Cal In-Home Operations Waivers Nursing Facilities Waiver (Parental income and resources do not apply.) 0 Developmental Services Waiver (Parental Income and resources do not apply.)

ZIP mde

Pn led n m e 1 VUa Telephone

STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES: Please verify that the above child is currently receiving Medi-Cal benefits and receiving waiver services.

Ccunty adaress (number Nee11

Slgnaure 01 state authcfmng -n

C~ty

>

White: Parent copy DHS 7071 (1104)

( 1

State address (numb% Sueell

Yellow- County copy

Stale

Tele~hone Rlnled name


ZIP m e

lit le

Cll y

( ) Stale ZIP code

-- -


Stale ol CaofcmlbHeenh and Hman S e w e r Agency

MEDI-CAL r NOTICE OF ACTION

Department of Developmental Services Waiver

Approval for Benefits

Department 01 Healm Savlce.

7

(COUNPT STAMP)

1 Notice date:

Case number: Worker name: Worker number: '

Worker telephone number:

J Office hours: Notice for:

The Department of Developmental Services Waiver program is limited to developmentally disabled persons who live at home and meet the admission criteria for an intermediate care facility for the developmentally disabled.

0 You are eligible for this program at no cost.

0 You are eligible for this program with a monthly share-of-cost of $

Please notify your worker if there are any changes in your medical condition, living situation, income, or property.

Always present your Benefits Identification Card (BIC) to your medical provider whenever you need care. This card is good as long as you are eligible for Medi-Cal. DO NOT THROW AWAY YOUR BIC.

The regulation which requires this action is California Code of Regulations, Title 22, Section 51346.

cc: Regional Center

PLEASE READ THE REVERSE SIDE OF THIS NOTICE.

k c 3 4 1 ~8102)

-- - - -



slate d Califmda-H&h and Hunan Services Agwnl 0- d H&h

NOTIFICACI~N DE ACCION r DE MEDI-CAL

1 Aprobaci6n de la Extensi6n de Beneficios

del Departamento de Se~ ic ios para Personas con lncapacidades Adquiridas al Nacer o

Durante el Desarrolo L (COUNTY STAMP)

_I

1 Fecha de la notificaci6n: Numero del caso: Nombre del trabajador: Nbmero del trabajador: Numero de telefqno del trabajador:

J Horas hlbiles: Notificacbn para:

El programa de Extensibn de Beneficios del Departamento de Servicios a Personas con lncapacidades Adquiridas al Nacer o Durante el Desarrollo se limita a personas incapacitadas, desde el punto de vista del desarrollo, que viven en el hogar, y que cumplen con 10s criterios de ingreso de un centro de convalecencia de cuidados intermedios para las personas incapacitadas desde el punto de vista del desarrollo.

0 Usted reune 10s requisitos para este programa sin costo alguno.

0 Usted reune 10s requisitos para este programa con una parte del costo mensual de $

Por favor, notifique a su trabajador(a), si hay algun cambio en su condici6n medica, situaci6n de vivienda, ingresos o bienes.

siempre presente su Tarjeta de Identificacibn de Beneficios (BIC) a su proveedor mkdico, cada vez que necesite atencibn. Esta tarjeta es vhlida mientras usted reuna 10s requisitos para recibir beneficios de Medi-Cal. NO TIRE SU BIC.

La regulacibn que exige esta acci6n es la Secci6n 51346, del Titulo 22, del Cbdigo de Regulaciones de California.

cc: Centro Regional

POR FAVOR LEA EL REVERS0 DE ESTA NOTIFICACI~N.

MC 341 (SP) 18/02)



Stale of CdtfornlbHeam and Hman Services Agenq Oepanmenl of Heann


Department of Developmental Services Waiver

Denial or Discontinuance of Benefits (COUNTY STAMP1

1 Notice date:

Case number: Worker name: Worker number: Worker telephone number:

J Once hours:

Notice for:

The Department of Developmental Services Waiver program is limited to developmentally disabled persons who live at home and meet the admission criteria for an intermediate care facility for the developmentally disabled.

0 Your benefits under this program will be discontinued effective the last day of

0 Your application date of is denied.

Here islare the reason(s) why:

0 Your property is over the limit of

0 The regional center has informed us that you are no longer eligible for waiver services.

0 You are now living in a community care facility.

You will receive another notice if you are eligible for another Medi-Cal program.

DO NOT THROW AWAY YOUR PLASTIC BENEFITS IDENTIFICATION CARD (BIC). You can use it again if ! you become eligible or are eligible for another Medi-Cal program.

The regulation which requires this action is California Code of Regulations, Title 22, Section 51346.

cc: Regional Center

PLEASE READ THE REVERSE SIDE OF THIS NOTICE.

MC 342 I&D21



%la ol Ca)danla--Halh and Human S m e s Agerm Oepatmanl d He& Sen-

NOTIFICACION DE ACCION r DE MEDI-CAL

Negacion o Descontinuacion de la Extensi6n de Beneficios del Departamento de Servicios a Personas con lncapacidades Adquiridas a1

Nacer o Durante el Desarrolo L ( C O M N STAMP)

1 Fecha de la notificaa6~ Nurnero del caso: Nombre del trabajador: Nurnero del trabajador: Nurnero de telt5fono del trabajador:

J Horas hAbiles: Notificacion para:

El programa de Extension de Beneficios del Departamento de Servicios a Personas con lncapacidades Adquiridas al Nacer o Durante el Desarrollo se limita a personas incapacitadas desde el punto de vista del desarrollo, que viven en el hogar y que cumplen con 10s criterios de ingreso de un centro de convalecencia de cuidados intermedios para las personas incapacitadas desde el punto de vista del desarrollo.

CJ Sus beneficios bajo este programa se descontinuaran a partir del ultimo dia de

0 Su fecha de solicitud del se niega.

A continuacidn se le da(n) la($ razon(es):

0 Sus bienes estan por encima del limite de

El centro regional nos ha informado que usted ya no reune 10s requisitos para 10s servicios de extension.

0 Usted ahora vive en un establecimiento de cuidado en la comunidad.

Usted recibira otra notificaci6n, si usted reune 10s requisitos para otro programa de Medi-Cal.

NO TIRE SU TARJETA DE IDENTIFICACION DE BENEFlClOS DE PL~TICO (BIC). Usted. puede usarla de nuevo si reune 10s requisitos para otro programa de Medi-Cal.

La regulation que exige esta accion es la Seccion 51346, del Titulo 22, del Codigo de Regulaciones de California.

cc: Centro Regional

SECTION NO.: 51346 MANUALLETTERNO.: 291 - DATE:09 /03 /04 19D-21


December 1,2003 CONTACTS Fa11 BEGIOIW CEHTEBS 360 - 380

r~ I I

REGIONAL CENTER

SECTION NO.: 51346

I 1 360 FRANK D. LANTERMAN REGIONAL 1 CENTER

3303 Wilshire Boulevard, Suite 700 LOS Angeles CA 9001 0

361 GOLDEN GATE REGIONAL CENTER 120 Howard Street, Fourth Floor San Francisco, CA 941 05-1 848

362 SAN DlEGO REGIONAL CENTER 14355 Ruffin Road, suite 205 San Diego, CA 92123-1 648

363 FAR NORTHERN REGIONAL CENTER 1377 East Lassen Avenue Chico, CA 95973

364 ALTA CALIFORNIA REGIONAL CENTER 2135 Butano Drive Sacramento, CA 95825

365 SAN ANDREAS REGIONAL CENTER 300 Orchard City Drive, Suite 170 Campbell, CA 95008

366 TRI-COUNTIES REGIONAL CENTER 520 East Montecito Santa Barbara, CA 93103

367 CENTRAL VALLEY REGIONAL CENTER 461 5 Marty Avenue Fresno, CA 93722

368 REGIONAL CENTER OF ORANGE COUNTY 801 Civic Center Drive, Suite 300 Santa Ana, CA 92701 -

MANUAL LETTER NO.: 29 1 DATE: 09/03/04 19D-22

MEDICAID WAIVER COORDINATOR

ALTERNATE MEDICAID WAIVER

COORDINATOR

Ardis Adrian, R.N. (21 3) 383-1 300 X 746 (213) 383-6526 (FAX) [email protected]

Candace Sultan, R.N. (41 5) 546-9222 X 400 [email protected]

Carol Jean Thomas, QMRP (858) 576-2985 cjthomas@?sdrc.org

Mary McCart, QMRP (530) 895-8633 [email protected]

Peggy Ann Feldt, RNMS, QMRP (91 6) 978-6378 [email protected]

Florence N. Yalung, District Manager Resource and Federal Programs (408) 341 -3485 [email protected]

Cheryl Wenderoth, QMRP (805) 884-721 0 (SB Office) (805) 485-31 77x251 (V Off.) [email protected]

Holly Lovett, QMRP (559) 738-221 0 1945 East Noble Visalia, CA 93292-1 51 6 [email protected]

Randy Laya, M.S (714) 796-5221 [email protected]

Grace Kotchouian, R.N. (21 3) 383-1 300 Sylvia Flores (213) 383-1300 X 706

Carla Kania, R.N. (41 5) 546-9222 X 200 (41 5) 546-1 91 0 (FAX)

Roy Carroll, QMRP (858) 576-2992 (858) 496-4327 (FAX)

Tamara Panther (530)222-8795 X 3360 P.O. BOX 49241 8 Redding, CA 96049 (530) 895-1501 (FAX)

(91 6) 489-6385 (FAX)

Ken Heritier, QMRP (408) 341-3514 (408) 376-0586 (FAX)

(805) 884-9374 (FAX)

Lidia Ramirez Garza, QMRP (559) 276-4487

(559) 276-4450 (FAX)

Lynn Maltz (714) 796-521 8

(714) 547-7278 (FAX)




COORDiNATOR

Clarice Schnepf, R.N. (909) 890-3428 (909) 890-3001 (FAX) [email protected]

(707) 444-3409 (FAX)

Marilyn Halloran, Sup. Adult Services Unit (707) 256-1248 [email protected]

(707) 256-1270 (FAX)

Melvina Mull (661) 327-8531 x 368 [email protected] (661) 324-5060 (FAX)

Judy Matthews, RN (626) 299-4788

(626) 281 -1 163 (FAX)

Cynthia Stakley, RN (213) 763-5631

(21 3) 744-8888 (FAX)

Laura Garabedian, R.N. (310) 543-1 71 1

(310) 540-9538 (FAX)

Transito Rivas (310) 258-4106 (31 0) 338-9744 (FAX)

REGIONAL CENTER

369 INLAND REGIONAL CENTER 674 Brier Drive San Bernardino, CA 92408

370 REDWOOD COAST REGIONAL CENTER 525 Second Street, Suite 300 Eureka, CA 95501

371 NORTH BAY REGIONAL CENTER 10 Executive Court, Suite A Napa, CA 94558

372 KERN REGIONAL CENTER 3200 North Sillect Avenue Bakersfield, CA 93308

373 EASTERN LOS ANGELES REGlONA L CENTER

1000 South Fremont Avenue Alhambra, CA 91802-7916

374 SOUTH CENTRAL LOS ANGELES REGIONAL CENTER 650 West Adams Blvd, Suite 400 Los Angeles, CA 90007

375 HARBOR REGIONAL CENTER Del Amo Business Plaza 21231 Hawthorne Boulevard Torrance, CA 90503

376 WESTSIDE REGIONAL CENTER 5901 Green Valley Circle, #320 Culver City, CA 90230-6938


Margie Henderson (909) 890-3425 (909) 890-3007 (FAX) [email protected]

Tina Moulton (707) 445-0893 X 363 [email protected]

Kay Bany, QMRP (707) 256-1 183 [email protected]

Rhea Schnurman (707) 566-3006 [email protected]

Cherylle Mallinson, MS, QMRP (661) 327-8531 x 246 [email protected]

Jesse Valdez, Manager of Specialized Svs., QMRP (626) 299-471 9 [email protected]

Fezem Shabaf, RN (213) 744-8850 [email protected]

Paula Fiebert, QMRP (31 0) 543-061 5 [email protected]

Marguerite Phillips, LCSW Director of Federal Revenue Programs (31 0) 543-0659 [email protected]

Bill Feeman, RN (31 0) 258-41 32 [email protected]



REGIONAL CENTER

377 VALLEY MOUNTAIN REGIONAL CENTER 7109 Danny Way Stockton, CA 95269

378 NORTH LOS ANGELES REGIONAL CENTER 15400 Sherman Way, Suite 170 Van Nuys, CA 91406-421 1

379 SAN GABRlELlPOMONA REGIONAL CENTER 761 Corporate Center Drive Pomona, CA 91 768

380 EAST BAY REGIONAL CENTER 7677 Oakport Street, Suite 1200 Oakland, CA 94621


Katina Richison, QMRP (209) 955-361 6 [email protected] (209) 478-3539 (FAX)

Anthony Hill (209) 955-3258 a [email protected] (209) 473-071 9 (FAX)

Laura Rankin, QMRP (81 8) 756-6270 [email protected]

Guadalupe Magallanes, QMRP

(909) 868-7793 gmagallanes.sgprc.org

Cristie Guss, M.S., QMRP (51 0) 383-1 375 [email protected]

Carolyn Bressler, QMRP (510) 383-1351 [email protected]


COORDINATOR

Joyce Young-Lofton, RN QMRP (209) 529-2626 X 2133 (Modesto) (209) 955-3276 (Stockton)

Shelbi Stoecklin, QMRP Federal Programs Spec. (209) 955-3672 [email protected]

Maria Bratley (818) 756-6381 (818) 756-6390 (FAX)

Liz Serna (909) 868-7655 (909) 622-5123 (FAX) Letha Sellars (909) 868-751 8

Bev Davis, QMRP (51 0) 383-1281 [email protected]

(510) 633-5020 (FAX) (510) 633-5021 (FAX) (510) 633-5022 (FAX)

MEDI-CAL ELIGIBILITY PROCEDURES MANUAL -- -

+ WHAT IS THE HOME AND COMMUNITY- BASED SERVICES (HCBS) WANER?

The HCBS Waiver is a way to fund certain services that allow a person who experiences developmental disabilities to live at home or in the community rather than having to go to live in a licensed health facility.

Costs for these services are funded jointly by the federal government's Medicaid program and the State of California.

+ WHAT IS "WAIVED"?

Certain federal Medicaid rules are "waived". allowing the state to provide services to people with developmental disabilities in ways that are not available to other people who are enrolled in Medicaid (which is called Medi-Cal in California). One federal condition of the Waiver is that those supports or services are different than those available through Medi-Cal.

+ DO I HAVE TO BE ON THE WAIVER TO RECEIVE REGIONAL CENTER SERVICES?

If you or your family member is eligible for the HCBS Waiver, it is good to enroll in it. That way many of the services that you choose will be partially paid for by the federal Medicaid program This usually means that more people like yourself or your family member can receive services.

Enrollment in the HCBS Waiver is a matter of choice. Unlike other states that restrict services to persons served under the HCBS Waiver, California's regional centers provide the full scope of state-funded services to all eligible persons.



Whether you are eligible for - and choose - enrollment in the HCBS Waiver or not, you or your family member will receive the same person-centered ' planning, opportunities to choose services and providers, and be ensured the same quality of care.

+ WHO BENEFITS FROM THE HCBS WAIVER?

To benefit from the HCBS Waiver you, or your family member, must meet three conditions. First, you must have "full scope" Medi-Cal eligibility - either through your own, your family's eligibility or, if you are under the age of 18, through something called "institutional deeming" (see below). Second, you must have a formal diagnosis of mental retardation or developmental disability and be a regional center consumer. Third, you must undergo an evaluation that determines that you would benefit fiom a certain level of care for your disabilities that would be available in a licensed health care facility for people who have mental retardation. This third qualification is important not because you will go to such a facility, but because the HCBS Waiver is designed to help people stay in the community rather than have to go to such a facility to get the services they need.

+ WHAT IS INSTITUTIONAL DEEMING?

Institutional Deeming is a special Medi-Cal eligibility rule that considers only the personal income and resources of a person under the age of 18 or a rnanied adult who is otherwise eligible for the Waiver. This allows a person who meets the criteria above to be determined as eligible for Medi-Cal regardless of his or her parent's or spouse's income and resources.

This is very helpful because typically a family's health insurance or income will not cover the total cost of these needed services.

Through "Institutional Deeming rules," the family may now obtain Medi-Cal benefits for needed services regardless of income.

This also allows that person to be eligible for all Medi-Cal services - not just those provided through the HCBS Waiver. This eligibility applies as long as the person is enrolled in the Waiver.

+ THE HCBS WAIVER Q U A L m FRAMEWORK

The goals of the HCBS Waiver are to ensure consumer choice of waiver services, consumer satisfaction, and to provide safeguards necessary to ensure the health and safety of each consumer in the program. These goals are accomplished through the following framework of quality assurance that focuses attention on:

> Consumer rights to due process, grievances, and personal decisions.

9 Consumer-centered service planning, and service modifications in response to changing needs.

> Consumer choice of qualified providers and monitoring of providers by the regional center.

9 Consumer health and safety.

9 A user-friendly enrollment process. The regional center determines eligibility for the Waiver based on current Medi-Cal status, the consumer's level of care needs and consumer choice. Consumers may also choose to disenroll or terminate their participation in the Waiver at any time.


.. ..

-- --


6 s State of California-Health and Human Services Agency

Caltfarnta Department of Health Services Depanment of Health Sentcer

Sandra Shewry Director

Arnold Schwarzenegger Governor

((SALUTATION)):

Medi-Cal In-Home Operations (IHO) Waiver Eligibility Notice Individual: ({BENENAMEa Social Security Number: ccSSN)) Date of Birth: ctDOBn Address: ~BENEADDRESSB Telephone: ((BENEPHONE))

This notice is to confirm that the above-named individual has been determined medically eligible for Medi-Cal IHO Waiver services by the Department of Health Services, In-Home Operations (IHO) Section.

If the individual is currentlv not a Medi-Cal beneficiary, helshe must contact ((COUNTYCONTACT)) in ((COUNTY)) County at ((COUNTYPHONE)), for information on how to complete the Medi-Cal application process used in your county.

If the individual currently is a Medi-Cal beneficiary whose eligibility needs to be redetermined, please contact ((COUNTYCONTACT)) in ((COUNTY)) County at ((COUNTYPHONE)) and request information on the Medi-Cal eligibly redetermination process. The county will send a notice to the individual advising himlher of this process.

Should you have any questions regarding this notice, please feel free to contact me, at (916) 552-9273.

Sincerely,

Carol Hausler, Eligibility Analyst In-Home Operations

Note to County: Requesting effective date of <DATE>

Do your part to help Califorma save energy. To leam more about saving energy, visit the following web site: www.consumerenergycenter.org/flexiindex.html

- --

Letter 1 1501 Cap~tol Avenue MS 4502 P 0 Box 942732, Sacramento. CA 94234-7320 (916) 552-9273

Intornot Addrocc smmrr dhc r s nnw

-



State of California-Health and Human Services Agency

Department of Health Services

Cal8fornla Depanmenl of Healzn Serrtces


Arnold Schwatzenegger Governor

((DATE))

((SALUTATION)):

Medi-Cal In-Home Operations (IHO) Waiver Eligibility Notice Individual: USENENAMEN Social Security Number: uSSNH Date of Birth: uDOBD Address: uBENEADDRESS~ Telephone: uBENEPHONEB

This notice is to confirm that the above-named individual has been determined medically eligible for Medi-Cal IHO Waiver services by the Department of Health Services, In-Home Operations (IHO) Section.

If the individual is currently not a Medi-Cal beneficiary, Los Angeles County will send hirnlher a Medi-Cal application that will need to be completed and retuned to the county by the date stated by the county.

If the individual currently is a Medi-Cal beneficiary whose eligibility needs to be redetermined, the county will send a notice to the individual advising himiher of this process.

Please note the individual does not need to contact Los Angeles County.

Should you have any questions regarding this notice, please feel free to contact me, at (916) 552-9273.

Sincerely,


cc: Ms. Julie Johnson Department of Public Social Services P.O. Box 92164 City of Industry, CA 91715-2164

Note to County: Requesting effective date of <DATE>

F;;;.;; m; Do your part to help California save energy. To learn more about saving energy, visit the following web site:

Letter 2 1501 Capitol Avenue, MS 4502; P.O. Box 942732; Sacramento, CA 94234-7320 (91 6) 552-9273

Intornof Arlrlrorc. ,mmu dhs cz nnu

SECTION NO.: 51346 MANUAL LETTER NO.: 291 DATE:og/o3/04 19D-29

- --


State of California-Health and Human Services Agency

Department of Health Services dKs


Arnold Schwalzenegger Govemw

Dear ((SALUTATION)):

Medi-Cal In-Home Operations (IHO) Waiver Eligibility Notice Individual: ((BENENAME)) Social Security Number: (tSSN, Date of Birth: ctDOBn Address: ((BENEADDRESSn Telephone: (tBENEPHONEm

This notice is to confirm that the above individual's wavier enrollment has been changed to the Medi-Cal In Home Operations (IHO) Waiver from the Department of Developmental Services (DDS) Wavier effective <<DATE>>. This change of enrollment does not require any action by the individual at this time and hislher eligibility remains the same as it was under the DDS Waiver.

A copy of this notice is being sent to ((COUNTYCONTACT)) in ((COUNTY)) County to notify them of the change from the Department of Developmental Services Waiver to the Medi-Cal IHO Waiver. This letter does not require any action on your part at this time.

Should you have any questions regarding this notice, please feel free to contact me at (916) 552-9273.

Sincerely,


cc: ((COUNTYCONTACT)) ((COUNTYDEPT)) ((COUNTYADDRESS)) ((COUNTYCITYSTATEZIP))

Note to County: Requesting effective date of <DATE> -

Do your part to help California save energy. To learn more about saving energy, visit the following web site:

Letter 3 1501 Capitol Avenue. MS 4502: P.O. Box 942732: Sacramento. CA 94234-7320 (91 6) 552-9273

l n t ~ r n n t Arlrlraec. tmrnr, rfhc r t nn,,

SECTION NO.: 51346 MANUAL LETTER NO.: 2 9 1 D A T E : O ~ / O ~ / O ~ 19D-30



MEDI-CAL IN-HOME OPERATIONS WAIVERS APPROVAL FOR BENEFITS

Depamslt d H e m Medi-Cat Program

1

L (COUKn STAMP)

_I

Notice date: Case number: Worker name: Workw number: Worker telephone nurnber: Oftie hours: Notice for:

The Medi-Cal In-Home Operations Waivers are limited to persons who require the nursing facility level of care or subacute services but who wish to live at home or in the community. The income and property of a parent is not used in the determination for the applicant or beneficiary child. Institutional deeming rules apply if the waiver applicant is living at home with a spouse.

0 You are eligible for this program at no cost.

a You are eligible for this program with a monthly share-of-cost of $

You do not have to fill out monthly or quarterly status reports to get Medi-Cal.

You must report within ten days any changes in your income, property, medical condition, or household situation.

You will have to complete a form for your Medi-Cal annual review.

Getting Medi-Cal does not reduce any time limits for the CalWORKS program.

Please notify your worker if there are any changes in your medical condition, living situation, income, or property.

Always present your Benefits Identification Card (BlC) to your medical provider whenever you need care. This card is good as long as you are eligible for Medi-Cal. DO NOT THROW AWAY YOUR BIC.

The regulation which requires this action is California Code of Regulations, Title 22, Section 51 346.

cc: In-Home Operations


MEDI-CAL ELIGIBILIN PROCEDURES MANUAL

Slae of W i i M a H h and HwMn Savhes Agemy E-?wimmt of Health MedbC* P-

NOTIFICACION DE LA ACCION r DE MEDI-CAL

1 APROBACI~N DE BENEFlClOS PARA OBTENER UNA EXTENSION A LOS SERVlClOS DE MEDI-CAL PARA EL

CUIDADO MEDICO EN EL HOGAR L (COUNTY STAMP)

_I

Fecha de la notificaaon:

1 Nurnem del caw: Nmbre del trabajador: Ntjrnero del trabajadw: Telbfono dd trabajadw: Horas de ofidna:

J Notificaci6n de:

La Extension a 10s Servicios de Medi-Cal para el Cuidado Medico en el Hogar, se limita a personas que requieren el nivel de atencion de un establecimiento de cuidado medico o servicios subagudos, per0 desean vivir en sus hogares o en la comunidad. Los ingresos y 10s bienes de uno de 10s padres no se toman en cuenta para determinar la elegibilidad del solicitante o del nifio beneficiario. Las reglas relacionadas a las personas que se consideran como si estuvieran en una institucion, se aplican si el solicitante o beneficiario esta viviendo en su hogar con su conyuge.

0 Usted es elegible para este programa, sin costo alguno.

0 Usted es elegible para este programa, per0 tendra que pagar mensualmente una parte del costo de $

Usted no tiene que llenar reportes mensuales o trimestrales para obtener beneficios de Medi-Cal.

Usted tiene que reportar, en un plazo de diez dias, cualquier cambio en sus ingresos, bienes, condicion medica o situacion en el hogar.

Usted tendra que completar un formulario para su evaluacion anual de Medi-Cal.

El obtener Medi-Cal no reduce ninglin limite de tiempo para el programa de CalWORKs.

Por favor notifique a su trabajador si hay cambios en su condicion medica, situacion de vivienda, ingresos o bienes.

Siempre presente su Tarjeta de Identificaci6n de Beneficios (BIC) a su proveedor medico, cada vez que necesite atenci6n medica. Esta tarjeta es valida mientras usted sea elegible para recibir beneficios de Medi-Cal. NO TIRE SU TARJETA (BIC).

La regla que exige esta accion se encuentra en la Seccion 51346, del Titulo 22, del Codigo de Regulaciones de California.




Slate d CdilanIbHedth and Human S- AWCy


MEDI-CAL IN-HOME OPERATIONS WAIVERS DENIAL OR DISCONTINUANCE OF BENEFITS

L I C O W STAMP)

_I

Notice date:

1 Case number: Worker name: Worker number: Worker telephone number: Office hours:

J Notice for:

The Medi-Cal In-Home Operations Waivers are limited to persons who require the nursing facility level of care or subacute services but who wish to live at home or in the community. The income and property of a parent is not used in the determination for the applicant or beneficiary child. Institutional deeming rules apply if the waiver applicant or beneficiary is living at home with a spouse.




0 Your property is over the limit of $

0 You no longer have approved waiver services.

0 You are no longerlnot living in the home.

You will receive another notice if you are eligible for another Medi-Cal program.

DO NOT THROW AWAY YOUR PLASTIC BENEFITS IDENTIFICATION CARD (BIC). You can use it again if you become eligible or are eligible for another Medi-Cal program.

The regulation which requires this action is California Code of Regulations, Title 22, Section 51 346.


SECTION NO.: 51346 MANUAL LETTER NO.: 291 DATE: 0 9 / 0 3 / 0 4 190-33


state of CalitanlbHeanh and Humsn Se~ces&"01

NOTIFICAC~ON DE LA ACCION f- 7 DE MEDI-CAL

NEGACION 0 DESCONTINUAC~ON DE BENEFlClOS PARA OBTENER UNA EXTENSION A LOS SERVlClOS DE MEDI-CAL PARA EL CUIDADO MEDICO EN EL HOGAR L

( C O U m STAMP) _I

Fecha de la notificacibn:

Nurnero del caso:

1 Nombre del trabajador: Numero del trabajador

Telefono del trabajador: Horas de oficina: Nolilicacion de:

J

La Extension a 10s Servicios de Medi-Cal para el Cuidado Medico en el Hogar, se limita a personas que requieren el nivel de atencion de un establecimiento de cuidado medico o servicios subagudos, per0 desean vivir en sus hogares o en la comunidad. Los ingresos y 10s bienes de uno de 10s padres no se toman en cuenta para determinar la elegibilidad del solicitante o del niiio beneficiario. Las reglas relacionadas a las personas que se consideran como si estuvieran en una institution, se aplican si el solicitante o beneficiario esta viviendo en su hogar con su conyuge.

0 Sus beneficios bajo este programa se descontinuaran a partir del ultimo dia de

0 Su solicitud con fecha del se ha negado.

Esta(s) eslson la(s) razon(es) por la cual su solicitud se ha negado:

fJ El valor de sus bienes esta por encima del lirnite de $

0 Su extension para recibir servicios no fue aprobada.

0 Usted ya no vivelno esta viviendo en el hogar.

Usted recibira otra notificacion si usted es elegible para otro programa de Medi-Cal.

NO TIRE SU TARJETA DE IDENTIFICACI~N DE BENEFICIOS (BIC). Usted puede utilizarla de nuevo, si vuelve a ser elegible para recibir beneficios de otro programa de Medi-Cal.

La regla que exige esta accion se encuentra en la Seccion 51346, del Titulo 22, del Codigo de Regulaciones de California.


MC 344 (SP) (10103)

SECTION NO.: 51346 MANUAL LETTER NO.: 29 1 - .- ' - .. DATE: 09/03/04 19D-34

... ..... - ................... ... _ _ - . - -

What a r e

a r e offered u n d e r t h e s e dlfferent programs?

0 0

request

O O

HOME- AND COMMUNITY-BASED SERVICES BRANCH

In-Home Operations (IHO) Section 1501 Capitol Avenue, MS 4502 P.O. Box 942732 Sacramento, CA 94234-7320 (9 16) 552-9 105 Main number for general information (916) 552-915 1 Fax

IHO Sacramento Regional Office Home- and Community-Based Services Waiver Intake Unit (91 6) 552-9 105 New intakes I information (916)552-9151 Fax

Case Management and EPSDT Units (916) 552-9 105 Information (916) 552-915 1 Fax

1HO Los Angeles Regional Office Case Management Unit 3 11 South Spring Street, 31d Floor Los Angeies, CA 90030 (2 13) 897-6774 Information (213) 897-7355193 14 Fax

Arnold Schwanenegger Governor

State of California

Grantland Johnson Secretary

Health and Human Services Agency

Medi-Cal Operations Division

$N-.f4f3iV% k; 01311:l~~4r~'IOhS

I I I L I

I I H I HOME- AND

COMMUNITY-BASED OPTIONS

IHO is the Section in DHS that oversees the development and implementation of home and community-based programs in the Medi-Cal program. IHO authorizes Pediatric Day Health Care (PDHC) facility services and medically necessary services in the home, including private duty nursing services, also known as shift nursing. These services may be available for Medi-Cal beneficiaries who are eligible for Early and Periodic, Screening, Diagnosis and Treatment (EPSDT) services and/or one of the following three federal waiver programs:

In-Home Medical Care (IHMC) Nursing Facility (NF) A/B Nursing Facility (NF) Subacute

EPSDT is a Medi-Cal benefit for individuals under the age of 21 who have full scope Medi-Cal eligibility. This benefit allows for periodic screenings to determine health care needs. Based upon the identified health care need, diagnostic and treatment services are provided. EPSDT PDHC and private duty nursing services arc provided in addition to other medically necessary Medi-Cal state plan services.

EPSDT services include all services covered by Medi-Cal. In addition to the regular Medi-Cal benefits, a beneficiary under the age of 21 may receive additionally medically necessary services. These additional services are known as EPSDT Supplemental Services and include: private duty nursing services from a Registered Nurse (RN) or a Licensed Vocational Nurse (LVN), Case Management, PDHC, and Nutritional and Mental Health Evaluations1 Services.

HCBS waivers allow states that participate in Medicaid - known as Medi-Cal in California - to develop creative alternatives for individuals who would otherwise require care in a nursing facility or hospital. Medi-Cal has, an agreement with the federal government that allows for waiver services to be offered in either a home or community setting. The services offered under the waiver must cost no more than the alternative institutional level of care. Recipients of HCBS waivers must have full scope Medi-Cal eligibility.

The available services under these HCBS waivers may include RN or LVN private duty nursing services, Certified Home Health Aide services, Case Management, Minor Home Modifications, Personal Emergency Response System, Family Training, Utility Coverage for life sustaining equipment, personal care services and respite.

There are a variety of providers, including the following:

For EPSDT -licensed and/or certified Medi-Cal providers and/or Individually enrolled supplemental private duty nursing service providers.

For HCBS waivers under IHO - licensed and certified Home Health Agencies, individual nurse providers and/or unlicensed caregivers.

A beneficiary may receive these home and community-based services as long as medically necessary.

Once the beneficiary has identified a provider of service, the provider must submit the request for services to 1HO on a Treatment Authorization Request (TAR) or similar request.

In addition to the TAR, the provider will also submit the following medical documentation:

Medical information which supports request for services, Assessment of care needs, i.e., nursing, personal care, etc., Plan of Treatment signed by a physician. and Home Safety Evaluation (for HCBS waiver services only)

These documents should support medical necessity for the requested HCBS waiver or EPSDT Supplemental services.

A request for any service needed for the home program or PDHC program may be submitted to IHO by the appropriate provider. These services must be medically necessary. Examples of other in-home services include:

Therapy services Equipment Transportation.

\\ rros~ r lo For more information about N O , I I o\r.ac-'r please call: I:( )R

rl I\THEI< (9 16) 552-9105 in Sacramento

<)l .E> 1 II.J\S'? (213) 897-6774 in Los Angeles

MEDI-CAL ELIGIBILITY PROCEDURES MANUAL -

Page I of 2 AlDS Medi-Cal Waiver Program

NOTICE OF ACTION (NOA) DENlAUREDUCTlON/TERMlNATlON OFAIDS MEDI-CAL WAIVER BENEFITS

Name Date of Notice

Address Date Services Expire

Medi-Cat 1.D. #

Waiver I.D. #

Medi-Cal regulations allow for the provision of certain AlDS Medi-Cal Waiver Program (MCWP) Home and Community-Based Services (HCBS) to persons who meet specific criteria. We have taken the following action with respect to services requested: for the reasons noted:

- '1. Denied your application or ended services for causes such as program noncomplianeor personal safety of caregivers or agency staff, specifically

- 2. Denied your application or ended services because you do not meet eligibility requirements as follows:

You have not submitted adequate proof of Medi-Cal eligibility, your Medi-Cal eligibility cannot be verified or you are not eligible or no longer eligible for Medi-Cal.

Your medical condition andlor medical needs do not currently meet the Nursing Facility or higher level of care and/or your diagnosis of asymptomatic HIV or AlDSrelated medical condition. does not meet eligibility requirements, or your 'K score" (the Cognitive and Functional Ability Scale) on the evaluation form that is used was too high.

- 3. Denied andlor reduced some portion of the services requested. Your medical condition andlor medical needs have improved necessitating a change in services ordered.

- 4. Continuing to provide HCBS to you is not cost effective (i.e., the estimated cost of providing you with those services exceeds cost guidelines set by the State).

- 5. Cost of services provided to you has reached the $13,209 calendar year annual cost cap. No more AIDS Medi-Cal Waiver services can be provided to you this calendar year.

- 6. The services you need are fully available to you through private insurance, Medicare, Medi-Cal, or another program.

- 7. You no longer desire HCBS.

- 8. Other

This NOA is required by Code of Federal Regulations. Title 42. Chapter IV, Subpart E, and the California Code of Regulations, Title 22, Section 51346. You have the right to ask for a State Hearing (SH) if you disagreed with any MCWP action. You only have ninety (90) days to ask for a hearing. The 90 days started the day after the MCWP gave or mailed you this notice. See page 2 for your appeal rights.

Denial or termination of AlDS MCWP benefits will not affect other medical or social services you are eligible to receive through California's Medi-Cal Program or other public benefit programs.

You may reapply for AIDS MCWP benefits at a future time if you believe you have become eligible.

Please call me for further information or if you have any questions. I may be reached at ( ) .

Sincerely,

Agency Representative Agency Name



. .- - - - . . -. . .

Page 2 of 2

STATE HEARING NOTICE - YOUR RIGHT TO APPEAL THE "NOTICE OF ACTION"

State Hearino Instructions-If you do not agree with the action described, you may request a State Hearing before an Administrative Law Judge employed by the Califomia Department of Social Services (CDSS). This hearing will beconducted in an informal manner to assure that everyone present is able to speak freely. Your case manager can help you request a hearing. If you decide to request a hearing, you must do so within 90 days of the dateof this notice. Your benefits will only continue until

the Services Expiration Date listed at the top of page 1 which is at least 10 days from the date of this notice. If you are currently receiving AlDS MCWP services and you request a SH before the Date Services Expire indicated at the top of this notice (at least10 days after the date of this notice), you will continue to receive services until a SH decision is made. If you are currently receiving AlDS MCWP services and you request a SH after the Date Services Expire, your AlDS MCWP services will stop on the Date Services Expire. You must verballv notifv vour case manaaer if vou file an appeal within this 10-day Deriod.

If you wish to request a State Hearing, please complete the attached Request for a State Hearing form and mail it to the address listed below or call the phone number provided. You must provide all the information on the form; any information missing from the request form may delay the processing of your State Hearing request. If you ask for a hearing the State Hearings Division will set up a file. You have the right to see this file before your hearing and to get a copy of the AlDS waiver provider's written position on your case at least two days before the hearing. The SHD may give your hearing file to the Califomia Department of Health Services and the United States Department of Health and Human Services per Welfare and Institutions Code Sections 10850 and 10950.

How to Reauest a State Hearing-You must either complete the attached Requestfora State Hearing form and mail it to:

Califomia Department of Social Services State Hearings Division 744 P Street, MS-19-37 Sacramento, CA 9581 4

Or call Toll-Free Number: (800) 952-5253 Teletypewriter v D ) only: (800) 952-8349

'Your Riahts" Pamphlet Available-"Your Rights under Califomia Welfare Programs pamphlet" issued by CDSS, provides useful information about State hearings. This pamphlet will be sent to you when your hearing request is processed.

Authorized Re~resentative-You can represent yourself at the State Hearing or be represented by a friend, attorney, or any other person; but, you are expected to arrange for the representative yourself. You can get help in locating free legal assistance by calling the toll-free number of the Public Inquiry and Response Unit (PIAR) at (800) 952-5253.

The PIAR office can also provide further information about your hearing rights. Assistance is available in languages other than English, including Spanish.

Code of Federal Regulations, Title 42,Section 431.220, Subpart E, Chapter IV, and the California Code of Regulations, Title 22, Section 51014.1, require that this Notice of ActionlState Hearing Notice be mailed at time of denial of an application when it is determined that you are not eligible for waiver services or at time of reduction or termination of existing services. The Notice must be mailed at least 10 calendar days (excluding the mailing date) before the effective date of reduction or termination of services.

MCWPZ (rev 05-2004) Attachment



Attachment REQUEST FOR A STATE HEARING

I

I am requesting a State Hearing because of Medi-Cal related action by , an AlDS Medi-Cal

Waiver agency related to the following reason(s): I

Name I

0 Denial of my application or ending of services for causes such as noncompliance or personal safely of caregivers or agency staff OR

Medi-Cal I.D. Number

Address

11 0 Denial of my application or ending of services because I do not meet eligibility requirements

City

a Denial andlor reduction of some portion of the service(s) requested OR 0 Ending of services because it is no longer cost effective to do so or the costs of services provided have

reached the $1 3,209 calendar year annual cost cap. 0 Denial of my application or ending of services because services I need are fully available through

private insurance, Medicare, Medi-Cal, or another program or I no longer desire Home and Community Based services.

Describe the basis for vour a ~ ~ e a l below: I Other

a I speak a language other than English and need an interpreter for my hearing. (The State will provide the interpreter at no cost to you.)

I

I "me: Phone Number:

Language:

)I Street Address:

Dialect:

City: State Zip Code

0 I want the person named below to represent me at this hearing. I give my permission for this person to see my records or go to the hearing for me. (This person can be a friend or relative but cannot interpret for you.)

Date: Mail to: California De~artment of Social Services

State ~ear ings Division 744 P Street, MS-19-37 Sacramento, CA 95814 Toll-Free Number: (800) 952-5253 Teletypewriter (TTD) only: (800) 952-8349

The AIDS Medi-Cal Waiver Program is administered by the Community Based Care Section, Office of AIDS, Department of Health Services, P.O. Box 997426, Sacramento, CA 95899-7426, (916) 449-5900.

11 CWP2 (rev 05-2004)

--



Programa d e Exenc ion para Personas c o n e l Sindrorne d e lnrnunodef ic iencia Adquir ida (SIDA) ba jo e l Programa d e Asistencia Medica d e Cal i fornia (Medi-Cat)

NOTlFlCAClON DE ACCION (NOA) NEGAClONlREDUCClONlDESCONTlNUACION DE LOS BENEFlClOS DE EST€ PROGRAMA

Nombre Fecha de la notification Fecha en que 10s

Direccidn servicios se descontinuarBn

Medi-Cal - # de identificacion

Exencion - # de identiRcaci6n

Los reglarnentos de Medi-Cal perrniten que se proporcionen ciertos servicios de casa y servicios basados en la comunidad (HCBS) a traves del Prograrna de Exencion bajo el Programa de Medi-Cal (MCWP) para Personas con SIDA si estas personas cumplen con 10s requisitos especificos. En relacion a 10s servicios que se solicitaron, hernos tomado la siguiente accion debido a las razones indicadas:

- 1. Negarnos su solicitud o descontinuamos sus servicios debido a rnotivos tales corno la falta de curnplimiento con 10s requisitos del programa o problernas en relacion a la seguridad personal de 10s proveedores de cuidado o del personal de la agencialoficina, especificarnente

- 2. Negamos su solicitud o descontinuarnos sus servicios debido a que usted no curnple con 10s requisitos de elegibilidad corno se indica a continuacion:

Usted no ha presentado las pruebas adecuadas de elegibilidad para Medi-Cal, su elegibilidad para Medi-Cal no se puede verificar, o no es o ha dejado de ser elegible para Medi-Cal.

[7 Actualrnente, su condicion rnedica ylo sus necesidades medicas no curnplen con 10s requisitos para el cuidado en un establecimiento de cuidado medico continuo no intenso o a un nivel mas alto ylo el diagn6stico de que usted tiene el virus de inrnunodeficiencia humana (VIH) o SIDA sin presentar sintornas no curnple con 10s requisitos de elegibilidad, o su clasificacion en la evaluation que se utiliza (la tabla de habilidad cognoscitiva y habilidad para funcionar) fue dernasiado baja.

- 3. Negarnos y/o redujimos una porcion de 10s servicios que se solicitaron. Su condicion rnedica ylo sus necesidades rnedicas han rnejorado lo cual ocasiono un carnbio en 10s servicios que se ordenaron.

- 4. El continuar proporcionandole 10s servicios HCBS ya no es lo mas econornico (es decir, el costo calculado para proporcionarle a usted esos servicios es mas que las norrnas de costo establecidas por el Estado).

- 5. El costo de 10s servicios que se le han proporcionado ha alcanzado 10s $13.209 que es lo maxirno permitido anualmente para un aiio civil. Para este atio civil, ya no puede recibir mas servicios bajo el MCWP para Personas con SIDA.

- 6. Los servicios que usted necesita estan cornpletarnente disponibles a traves de su seguro privado, Medicare (seguro medico federal), Medi-Cal, u otro prograrna.

- 7. Usted ya no quiere 10s servicios HCBS

- 8. Otra razon:

Esta notificacion de accion es un requisito del C6digo de Ordenamientos Federales, Titulo 42, Capitulo IV. Subparte E, y el Codigo de Ordenamientos de California, Titulo 22, Seccibn 51346. Usted tiene derecho a solicitar una audiencia con el estado (SH) si usted no esta de acuerdo con alguna acci6n en relacion al MCWP. Tiene solamente noventa (90) dias para solicitar una audiencia. Los 90 dias ernpezaron a contar al siguiente dia de cuando el MCWP le dio o le envi6 por coneo esta notificaci6n. Para 10s derechos que tiene para apelar, vea la pagina 2.

La negacion o descontinuacion de 10s beneficios del MCWP para Personas con SIDA no afectara otros servicios rn6dicos o sociales para 10s cuales usted es elegible bajo el Prograrna de Medi-Cal u otros prograrnas de beneficios publicos.

En el futuro, puede volver a solicitar 10s beneficios del MCWP para Personas con SIDA si usted Cree que ya es elegible.

Para mas inforrnacion o si tiene alguna pregunta, por favor Ilarnerne. Mi nurnero de telefono es I ) .

Atentarnente.

Representante de la agencialoficina Nornbre de la agencialoficina



NOTIFICACION DE UNA AUDlENClA CON EL ESTADO - SU DERECHO A APELAR LA "NOTIFICACION DE ACCION"

lnstrucciones en relacion a una audiencia con el estado-Si usted no esth de acuerdo con la acci6n descrita, usted puede solicitar una audiencia con el estado ante un juez de leyes administrativas empleado por el Departamento de Servicios Sociales de California (CDSS). Esta audiencia se llevara a cabo en una manera informal para asegurar que todas las personas presentes puedan hablar libremente. La persona encargada de su caso puede ayudarle a solicitar una audiencia. Si usted decide solicitar una audiencia, tiene que hacerlo antes de que pasen 90 dias a partir de la fecha de esta notificacion. Sus beneficios solamente continuaran hasta la "Fecha en qua 10s beneficios se descontinuar5n" que aparece en la parte de arriba de la pagina 1, la cual es al menos 10 dias despubs de la fecha de esta notificacibn. Si actualmente esth recibiendo servicios bajo el MCWP para Personas con SlDA y usted solicita una audiencia w n el estado antes de la "Fecha en que 10s beneficios se descontinuarAnn anotada en la parte de arriba de esta notificacion (a1 menos 10 dias despues de la fecha de esta notificaci6n). usted continuare recibiendo 10s s e ~ c i o s hasta qua se emita la decision de la audiencia con el estado. Si actualmente esta recibiendo servicios bajo el MCWP para Personas con SlDA y usted solicita una audiencia w n el estado despubs de la "Fecha en que 10s beneficios se descontinuahn", 10s servicios se descontinuaran en dicha fecha. Si usted presenta una apelacion antes aue se termine el Deriodo de 10 dias. tiene aue notiffcarte verbalmente al trabaiadorencaraado de su caso.

Si desea solicitar una audiencia con el estado, por favor complete el formulario de "Peticion para una audiencia con el estado" adjunto y envielo por correo a la direccion que aparece abajo o llame al numero de telbfono que se proporciona. Usted tiene que proporcionar toda la informacion en el formulario; cualquier inforrnacion que falte en el formulario pudiera atrasar la tramitacion de su peticion para una audiencia con el estado. Si usted solicita una audiencia, la Division de Audiencias Administrativas preparara un expediente. A1 menos dos dias antes de su audiencia, usted tiene derecho a ver su expediente y a recibir una copia escrita de la declaration de posicibn sobre su caso del proveedor de la exencion para las personas con SIDA. De acuerdo a lo estipulado en las Secciones 10850 y 10950 del Codigo de Bienestar Publiw e Instituciones, la Division de Audiencias Administrativas puede darle su expediente de la audiencia al Departamento de Servicios de Salud de Califomia y al Departamento de Servicios de Salud y Servicios Humanos de 10s Estados Unidos.

Corno solicitar una audiencia con el estado--Usted puede completar el forrnulario de "Peticion para una audiencia con el estado" adjunto y enviarlo por correo al Departamento de Servicios Sociales de California (CDSS) a la siguiente direccion:

California Department of Social Services State Hearings Division P.O. Box 944243 Sacramento, CA 94244-2430

o puede llamar al Numero de teldfono gratuito: (800) 952-5253 Teletipo (TIY) solamente: (800) 952-8349

Folleto disponible acerca de sus derechos-El folleto "Sus derechos bajo 10s programas de asistencia publica de California" publicado por el CDSS le proporciona informacidn util acerca de las audiencias con el estado. Le enviaran este folleto una vez que se tramite su peticidn para una audiencia.

Reoresentante autorizado--En la audiencia con el estado, se puede representar a si mismo o puede ser representado por un amigo, abogado, o cualquier otra persona; pero, usted tiene que hacer 10s arreglos para tener a un representante. Puede obtener ayuda para localizar asesoramiento legal sin costo llamando al numero de telbfono gratuito de la Oficina de Preguntas y Respuestas al Publico (PIAR) al (800) 952-5253.

La Oficina de PIAR tambibn le puede proporcionar m6s informacibn acerca de sus derechos en relacion a una audiencia. Esta informacion se proporciona en varios idiomas aparte del ingles, incluyendo el espafiol.

' La Seccibn 431.220 del C6dioo de Ordenamientos Federales. Titulo 42. Capitulo IV, Subparte E, y la Secci6n -- -. .~ - - -- - -

51014.1 del Codigo de ~rdekmientos de California, Titulo 22, estipulan qie esta ~otif icaci6n de accionlNotificacion de una audiencia con el estado se tiene que enviar por correo cuando se niegue una solicitud debido a que se determino que usted ya no es elegible para 10s servicios bajo una exencion o cuando se reduzcan o descontin~jen 10s servicios actuales. La notificacion se tiene que enviar por correo al rnenos 10 dias consecutivos (excluyendo la fecha en que se envio) antes de la fecha en que entre en vigor la reduccion o descontinuacion de 10s servicios.

SECTION NO.: 51346 MANUAL LETTER NO.: 2 91


PETlClON PARA UNA AUDlENClA CON EL ESTADO

I

Estoy solicitando una audiencia con el estado debido a una accion relacionada a Medi-Cal que tom6 , una agencialoficina que

proporciona exenciones para personas con SlDA para el Programa de Medi-Cal. El motivo (o motivos) aparece a continuacion:

Nornbre I

p Negation de mi solicitud o descontinuacidn de 10s servicios debido a motivos tales como la falta de cumplimiento con 10s requisitos del programa o problemas en relacion a la segundad personal de 10s proveedores de cuidado o del personal de la agencialoficina, Q

N~imero de Identificacion de Medi-Cal

Direcci6n

p Negation de mi solicitud o descontinuacion de 10s servicios debido a que no cumplo con 10s requisitos de elegibilidad. Q I

Ciudad

I p Negacion ylo reduccibn de una portion de lor servicios solicitados. Q I1 p Descontinuacion de 10s servicios debido a que el proporcionar 10s servicios ya no es lo mas economico o

porque el costo de 10s servicios proporcionados ha alcanzado 10s $13,209 que es lo maximo permitido anualmente para un atio civil. I

p Negacion de mi solicitud o descontinuacion de 10s servicios debido a que 10s servicios que necesito estan completamente disponibles a traves de un seguro privado, Medicare (seguro medico federal), Medi-Cal, u otro programa o debido a que yo ya no quiero 10s servicios de casa y basados en la comunidad.

Otro motivo: escriba a continuacion en aue se basa su apelacion: I

I p Quiero que la persona cuyo nombre aparece a continuacibn me represente en esta audiencia. Otorgo el

permiso para que esta persona vea mis expedientes o asista a la audiencia en mi nornbre. (Esta persona puede ser un amigo o pariente per0 no puede ser su interprete.)

Hablo otro idioma que no es el ingles y necesito un interprete para mi audiencia. (El Estado le proporcionarh un interprete sin costo para usted.) -

I

Idioma:

Nombre: Nljmero de telbfono:

Dialecto:

Domicilio:

Ciudad: Estado C6digo postal

I

Finna: Envie por coneo a: California Department of Social Services

State Hearings Division P.O. Box 944243 Sacramento. CA 94244-2430 Nljmero de telefono gratuito: (800) 952-5253 Teletipo (lTY) solamente: (800) 952-8349

El Programa de Exencion para Personas con SlDA bajo el Programa de Medi-Cal es administrado por la Seccion del Cuidado Basado en la Comunidad en la Oficina del SlDA en el Departamento de Servicios de Salud; la direccion y numero de telefono son: AIDS Medi-Cal Waiver Program, Community Based Care Section, Office of AIDS, Department of Health Services, 61 1 N. Seventh Street, P.O. Box 942732, Sacramento, CA 94234-7320,

[I (916) 4450553. j MCWP (SP) (Rev. 02-2001)



1 CITY OF OAKLAND (PSA 9) (510) 238-3762 FAX # (510) 238-7696 Analyst: Gloria Abemethy EMAIL: ljohnso~,oaklandnet.com ~ u r s i : Vacant

Linda Johnson, Site Director Multipurpose Senior Services Program City of Oakland Department of Human Services 150 Frank G. Ogawa Plaza, Suite 4340 Oakland, California 946 12

2 COUNTY OF SANTA CRUZ HUMAN (831) 454-4600 FAX # (831) 454-4610

RESOURCES AGENCY (PSA 13) EMAIL: hra26lmhra.co.santa-cruz.ca.us Analyst: John Curnmins Nurse: Sheny DeBarbien

3 ALTAMED HEALTH SERVICES CORP. (PSA 25)

Analyst: John Curnmins Nurse: Vacant

Hugo Romo, Site Director Dzrect Line: (323) 307-0229

Vangie Reichwein Direct Line: (323) 307-0228 Claudia Gallegos Dired Line: (323) 307-0212 Martha Ocarnpo Direct Line: (323) 307-021 4 Anwar Zoueihid Direct Line: (323) 307-0213

Francie Nedeld, Program Manager Multipurpose Senior Services Program Adult and Long-Term Care Services County of Santa Cruz Human Resources Agency 1400 Emeline Avenue, Building K P.O. Box 1320 Santa CNZ, California 95061

(323) 307-0200 FAX # (323) 307-0294 EMAIL: [email protected]

Hugo Romo, Site Director Multipurpose Senior Services Program AltaMed Senior Health and Activity Center 5 12 S. Indiana Street Los Angeles, California 90063

*Marie Tones, Senior Vice-President, Long-Term Care and Government Relations

*AU correspondence should have cc to . . Marie ~ o & e s .

4 JEWISH FAMILY SERVICE OF 1323) 937-5930 FAX # (323) 954-1319

Los ANGELES (PSA 25) EMAIL: pp4odman@ifsmss~.org

Analyst: John Curnmins Nurse: Sheny DeBarbieri Pem S. Sloane Goodman, Site Director

Multipurpose Senior Services Program Jewish Family Service of Los Angeles 330 North Fairfax Avenue Los Angeles, California 90036

02-23-2004 MSSP Site Roster



Analyst: Gloria Abernethy Nurse: Sherry DeBarbieri

Denise Likar, Site Director (562) 492-9878, Ext. 138 Direct Line: (562) 981 -0328

Denise Likar, Site Director Multipurpose Senior Services Program Senior Care Action Network Health Plan, Inc. 2501 Cherry Avenue, Suite 380 Signal Hill, California 90755

6 INSTITUTE ON AGING (PSA 6) 1415) 750-4150 FAX # (415) 750-4196 Analyst: Larry Leboda EMAIL: [email protected]~.orp, Nurse: Sherry DeBarbien'

E. Anne Hinton, Director Multipurpose Senior Services Program Case Management Services MSSP/ Linkages Program

E. Anne Hinton, Site Director Institute on Aging Direct Line: (4 1 5) 750-4 1 50, Ext. 300 3626 G e q Boulevard

San Francisco, California 941 18

7 SAN DIEGO COUNTY AGING AND (858) 495-5885 FAX # (858) 495-5080 INDEPENDENCE SERVICES (PSA 23) EMAIL: richard.wann@,sdcounty.ca.~ov

Analyst: John Cummins Nurse: Sherry DeBarbieri

Rick Wanne, Site Director Direct Line: (858) 495-5097

8 COMMUNITY CARE MANAGEMENT CORPORATION (PSA 26)

AKA: UKIAH Analyst: Gloria Abernethy Nurse: Vacant

Cynthia D. Coale, Executive Director ~ i l t i ~ u r ~ o s e senior Services Program Community Care Management Corporation

Main Office: 301 South State Street Ukiah, California 95482

Rick Wanne, Site Director Multipurpose Senior Services Program Aging & Independence Services County of San Diego 9335 Hazard Way, Suite 100 San Diego, California 92 123

(707) 468-9347 FAX # (707) 468-5234

Satellite Address b Telephone #s: 14642 "C" Lakeshore Drive Clearlake, California 95422 (707) 995-70 1 O/F=: (707) 995- 1830

490 North Harold Street - P.O. Box 1925 Fort Bragg, California 95437 (707) 964-4027/Fax: (707) 964-92 14

9 HUMBOLDT SENIOR RESOURCE (707) 443-9747 FAX # (707) 444-2065 CENTER, INC. (PSA 1) EMAIL: nconlo&,humsenior.org and

Analyst: Larry Lboda Nurse: Vacant Nancy Conlon, Site Director

Multipurpose Senior S e ~ c e s Program Humboldt Senior Resource Center, Inc. 19 10 California Street Eureka, California 9550 1



. . - . - . . . - . . . . . . . . . - - . - . . .


10 CALIFORNIA STATE U N ~ R S I T Y , (530) 898-5082 FAX # (530) 898-4870

CHICO (PSA 3) EMAIL: ahostette~csuchico.edu

Analyst: Gloria Abemethy Nurse: Vacant

Arlene Phalen Hostetter, Site Director Direct Line: (530) 898-61 91

Arlene Phalen Hostetter, Site Director Multipurpose Senior Services Program Area Agency on Aging, PSA 3 California State University, Chico 2491 Carmichael Drive, suite 400 Chico, California 95928-7 132

1 1 SONOMA COUNTY AREA AGENCY (707) 565-5970 FAX # (707) 565-5957

ON AGING (PSA 27) EMAIL: [email protected]

Analyst: Gloria Abernethy Nurse: Vacant

Diane Kaljian, Site Director Direct Line: (707) 565-5932

Diane Kaljian, Site Director Multipurpose Senior Services Program Sonoma County Area Agency on Aging - .

P.O. Box 4059- Santa Rosa, California 95402-4059

12 UNIVERSITY OF CALIFORNIA, (916) 734-5432 FAX # (916) 454-3070

DAVIS CARE MANAGEMENT (PSA 4) EMAIL: [email protected]

Analyst: Gloria Abemethy Nurse: Sherry DeBarbieri

Paula Bosler, Interim Site Director Direct Line: (91 6) 734-6043

Paula Bosler, Interim Site Director Multipurpose Senior Services Program University of California, Davis Care Management 3700 ~ u s i n e s s Drive, Suite 130 Sacramento, California 95820

13 COUNTY OF SAN MATEO DEPT. OF (650) 573-3900 FAX # (650) 573-2310

HEALTH SERVICES (PSA 8) EMAIL: pborrell~,co.sanmateo.ca.us

Analyst: Wendy Pride Pam Bonelli, Site Director Nurse: Vacant M U ~ ~ ~ D U ~ D O S ~ Senior Services Program

Pam Borrelli, Site Director Direct Line: (650) 573-351 2

Chris Rodriguez, Supervisor Direct Line: (650) 573-2703

~ ~ i n g ' 86 Adult Services Division -

Department of Health Services. Countv of San Mateo P.O. Bbx 5892 San Mateo, California 94403

14 STANISLAUS COUNTY COMMUNITY (209) 558-2233 FAX # (209) 558-2681

SERVICES AGENCY (PSA 30) EMAIL: Stamme~mai1.co.stanis1aus.ca.u~

Analyst: John Cummins Nurse: Vacant

Egon Stammler, MSW, Site Director Direct Line: (209) 652-1 755

Egon Stammler, MSW, Site Director Multipurpose Senior Services Program Stanislaus County Community Services Agency P.O. Box 42 Modesto. California 95353-0042

02-23-2004 MSSP Site Roster 3



15 COUNTY OF SANTA BARBARA (805) 346-8385 FAX # (805) 346-8386 PUBLIC HEALTH DEPARTMENT (PSA 17) EMAIL: [email protected]

Analyst: John Cummins Nurse: Sheny DeBarbieri

Susan Lindman, Site Director Multipurpose Senior Services Program County of Santa Barbara Public Health Department 2125 South Centerpointe Parkway Santa Maria, California 93455- 1340

Santa Barbara Site Address: 345 Carnino Del Remedio Third Floor, Building 4 Santa Barbara, California 93 1 10 (805) 68 1-5452

16 HUNTINGTON MEMORUU, HOSPITAL (626) 397-31 10 FAX # (626) 397-2996 (PSA 19)

Analyst: Wendy Pride Nurse: Sherry DeBarbieri

Eileen Koons, M.S.W., Director of Government Programs

Direct Line: (626) 397-201 1 Pager (626) 932-91 97 Fax: (626) 397-2982

Eileen Koons, M.S.W., Director of Government Programs

Multipurpose Senior Services Program Senior Care Network Huntington Memorial Hospital 837 South Fair Oaks Avenue, Suite 100 Pasadena. California 9 11 05-26 19

17 SAN BERNARDINO (PSA 20) (909) 89 1-9016 FAX # (909) 89 1-9039 Analyst: Wendy Pride EMAIL: ceklun~~hss.sbcounty.pov Nurse: Sheny DeBarbieri

Carl Eklund, Site Director Multipurpose Senior Services Program County of San Bernardino - East Valley Department of Aging and Adult Services Senior Home and Health Care 686 E. Mill Street, Second Floor San Bernardino, California 924 15-0640

18 COUNTY OF ORANGE (714) 825-3000 FAX # (714) 825-3155 SOCIAL SERVICES AGENCY (PSA 22) EMAIL: cfon~ssa.co.orange.ca.us

Analyst: Larry Leboda Nurse: Vacant

Chrisy Fong, Site Director Direct Line: (71 4) 825-3 1 0 7

Chrisy Fong, Site Director Multipurpose Senior Services Program Social Services Agency County of Orange P.O. Box 22006 Santa Ana, California 92702-2006




20 COUNCIL ON AGING (408) 296-8290 FAX # (408) 243-4708 OF SILICON VALLEY, INC. (PSA 10) EMAIL: mss~ , scccoa .o rg

Analyst: John Cummins Nurse: Vacant

*Stephen M. Schmoll, Executive Director Council on Aging of Silicon Valley, Inc. 2 1 15 The Alameda San Jose. California 95 126

Trudi Stone, Site Director Multipurpose Senior Services Program Case Management Services Council on Aging of Silicon Valley, Inc. 2 1 15 The Alameda San Jose, California 95126

"Correspondence i s addressed to S. Schmoll.

2 1 FRESNO-MADERA AREA AGENCY (559) 453-4405 FAX # (559) 453-51 11

ON AGING (PSA I 4) EMAIL: btrevarrowG!fmaaa.orq

Analyst: Gloria Abemethy Nurse: Vacant

Brian Trevarrow, Deputy Director Direct Line: (559) 488-3821

Brian Trevarrow, Deputy Director Multipurpose Senior Services Program Fresno-Madera Area Agency on Aging 2085 East Dakota Avenue Fresno, California 93726

*2220 Tulare Street, Suite 1200 Fresno, California 9372 1-2 106

*Mail all "Correspondence" t o this address.

22 SAN JOAQUIN CO~NTY (PSA 1 1 ) (209) 468-2202 FAX # (209) 468-2207 Analyst: Wendy Pride EMAIL: wmoor&co.san-ioaquin.ca.us Nurse: Sheny DeBarbien

Wendy Moore, Site Director *Joseph E. Chelli. Director Multipurpose Senior Services Program San Joaquin County San Joaquin County Human Services Agency P.O. Box 201056 P.O. Box 201056 Stockton, California 95201-3006 Stockton, California 95201-3006 (209) 468-3805 Direct Line: (209) 468- 1650 Fax: (209) 468-1985 *Correspondence is addressed to Joseph Chelli.

23 IMPERIAL COUNTY WORK TRAINING (760) 352-6181 FAX # (760) 352-6332 CENTER (PSA 24) EMAIL: [email protected]

Analyst: John Cummins Nurse: Sheny DeBarbien Arnold Alvarez, Site Director

Multipurpose Senior Services Program Imperial County Work Training Center, Inc. 2 10 Wake Avenue El Centro, California 92243

24 RIVERSIDE (PSA 21) (909) 697-4697 FAX # (909) 697-4667 Analyst: Wendy Pride EMAIL: [email protected] Nurse: Vacant

Ed Walsh, Site Director Multipurpose Senior Services Program Riverside County Office on Aging 6296 Rivercrest Drive, Suite K

Ed Walsh, Site Director Riverside, California 92507 Direct Line: (909) 697-4697, Ext. 229




25 GOLDEN UMBRELLA (PSA 2) (530) 223-6034 FAX # (530) 223-0658 AKA: Redding EMAIL: mcalkin~chw.edu Analyst: Larry Leboda Nurse: Vacant Mark Calkins, Site Director

Multipurpose Senior Services Program Golden Umbrella

Mark Calkins, Site Director 2227 College View Drive Direct Line: (530) 226-3013 Redding, California 96003

26 MARIN ~PSA 5) (415) 491-7960 FAX # (415) 472-7569 Analyst: Gloria Abemethy Nurse: Sherry DeBarbieri

Bernadette Sweeney, Site Director Direct Line: (4 1 5) 4 1 9-3602

Bernadette Sweeney, Site Director Multipurpose Senior Services Program Seniors At Home Jewish Family and Children's Services 600 Fifth Avenue San Rafael, California 9490 1

27 CONTRA COSTA (PSA 7) (925) 335-8710 FAX # (925) 335-8738 Analyst: Larry Leboda EMAIL: 1anders~ehsd.co.contra-c0sta.ca.u~ or Nurse: Sherry DeBarbieri

Linda Anderson, Site Director Multipurpose Senior Services Program Contra Costa County Office on Aging 2530 Arnold Drive, Suite 300 Martinez, California 94553

28 MERCED COUNTY (PSA 3 I) (209) 385-3000, Ext. 5200 Analyst: Wendy Pride FAX # (209) 725-3988 Nurse: Sherry DeBarbieri EMAIL: [email protected]

Richard Readel, MSW, Supervisor Direct Line: (209) 722-1 738, Ext. 31 67 Fax #: (209) 725-3837

Rhonda L. Walton, Deputy Director Multipurpose Senior Services Program Merced County Human Services Agency 2 115 West Wardrobe Avenue P.O. Box 112 Merced, California 9534 1-01 12

29 COUNTY OF KERN (661) 868-1095 FAX # (661) 868-0921 KERN COUNTY AGING AND ADULT EMAIL: [email protected]

SERVICES Analyst: Wendy Pride Nurse: Sherry DeBarbieri

Robin Garden, Site Director Multipurpose Senior Services Program County of Kern Kern County Aging and Adult Services 5357 Trwctun Avenue Extension Bakersfield, California 93309


SECTION NO.: 51346 MANUAL LETTER NO.: 29 1 DATE: 0 9 / 0 3 / 0 4 19D-48

MEDbCAL ELIGIBILITY PROCEDURES MANUAL

30 MONTEREY (PSA 32) (831) 755-3403 FAX # (831) 751-1729 Analyst: Larry Leboda EWL: [email protected] Nurse: Vacant

Andy Williams, Site Director Andy Williams, Site Director Multipurpose Senior Services Program Direct Line: (831) 755-3467 Monterey County Department of Social Services

713 La Guardia Street, Suite A Margarita Robles Salinas, California 93905 Fiscal Officer 1000 S. Main Street, Suite 306 Salinas, California 9390 1

3 1 NAPA/SOLANO (PSA 2 8 ) (707) 644-6612 FAX # (707) 644-7905 Analyst: Larry Leboda EMML: [email protected] Nurse: Vacant

Leanne Martinsen, Executive Director Multipurpose Senior Services Program

Kelly Hiramoto, LCSW, Supervisor Area Agency on Aging Serving Napa 86 Solano MSSPJLinkages Serving Napa & Solano 601 Sacramento Street, #I401 Direct Line: (707) 643-51 70, Ext. 20 Vallejo, California 94590

32 AREA 12 AGENCY ON AGING (PSA 1 2 ) (209) 532-6272 FAX # (209) 532-6501 Analyst: Larry Leboda EMAIL: aemmemarea 12 .org Nurse: Sherry DeBarbieri

Adam Emmer, Site Director Multipurpose Senior Services Program Area 12 Agency on Aging 13975 Mono Way, Suite E Sonora, California 95370

33 KINGS/TULARE (PSA 15) (559) 730-9921 FAX # (559) 624-1042 Analyst: John Cummins EMAIL: epadill@,tularehhsa.org Nurse: Vacant

Elissa Padilla, Site Director ELissa Padilla, Site Director Multipurpose Senior Services Program Phone Number & Ext: (559) 730-9921, Ext. 31 3 KingsITulare Area Agency on Aging

3500 West Mineral King Avenue, Suite A Pamela Nelson, Supervisor Visalia, California 9329 1

34 VENTURA (PSA 1 8 ) (805) 477-7300 FAX # (805) 477-7312 Analyst: John Cummins ENLAIL: maryleu.~a~va~mail.co.ventura.ca.us Nurse: Sherry DeBarbieri

Mary Leu Pappas, Site Director Multipurpose Senior Services Program County of Ventura Area Agency on Aging 646 County Square Drive, Suite 100 Ventura, California 93003-9086



- - -


Analyst: Gloria Abemethy EMAIL: [email protected]~ Nurse: Vacant

Janet Walker-Conroy, Public Guardian, Director Janet Walker-Conroy, Public 'Guardian, Director Multipurpose Senior Services Program Direct Line: (530) 621-631 7 El Dorado County Accounting/Contract OKice Department of Community Services 937 Spring Street 630 Main Street Placerville, California 95667 Placerville, California 95667 Direct Line: (530) 621-61 65

36 HE COUNTY OF YUBA (530) 749-6775 FAX # (530) 749-6244 - - - - - - - -

(PSA 4) Analyst: Larry Leboda Nurse: Vacant

Ginny Tuscano, Program Manager Direct Line: (530) 749-6 775

Ginny Tuscano, Program Manager Multipurpose Senior Services Program Yuba County Health and Human Services Department 6000 Lindhurst Avenue, Suite 700 C Marysville, California 95901

Analyst: Gloria Abernethy Nurse: Vacant

Mary Anne Mendall, Site Director Direct Line: (51 0) 574-2062

Mary Anne Mendall, Site Director Multipurpose Senior Services Program City of Fremont 3300 Capitol Avenue Fremont, California 94537-5006

38 INYO-MONO AREA AGENCY ON (760) 873-6364 FAX # (760) 873-5103

AGING (PSA 16) EMAIL: [email protected]

Analyst: Larry Leboda Charles Broten, Director Nurse: Vacant Multipurpose Senior Services Program

Inyo-Mono Area Agency on Aging P.O. Box 1799 Bishop, California 9351 5

39 HUMAN SERWCES ASSOCIATION (562) 806-5400 FAX # (562) 806-1006 (PSA 19) EMAIL: [email protected]

Analyst: Wendy F'ride Nurse: Sherry DeBarbieri Darren Dunaway, Senior Services Director

Multipurpose Senior Services Program Human Services Association 6800 Florence Avenue Bell Gardens, California 90201




40 PARTNERS IN CARE FOUNDATION (818) 526-1780, EXT. 108 (PSA 19) FAX # (818) 526-1788

Analyst: Wendy Pride EWL: [email protected] Nurse: Sherry DeBarbieri

James Cook, Director Multipurpose Senior Services Program Partners In Care Foundation 10 1 South First Street, Suite 1000 Burbank, California 9 1502

4 1 CALOPTIMA (PSA 22) (714) 246-8400 FAX # (714) 481-6536 Analust: L a w Leboda EMAIL: ipiilo@,calovtima.org NUT&: she& DeBarbieri

Jim Pijloo, Site Director Direct Line: (71 4) 246-8 773

Jim Pijloo, Site Director Multipurpose Senior Services Program CalOptima 1120 West La Veta Avenue, Suite 200 Orange, California 92868

43 PARTNERS IN CARE FOUNDATION- (310) 632-9980 FAX # (310) 632-9984

SOUTH (PSA 19) EWL: j c o o ~ ~ i c f ~ o r g

Analyst: Wendy Pride James Cook, Director Nurse: Sherry DeBarbien' Multipurpose Senior Services Program

Partners In Care Foundation-South 3737 E. Martin Luther King Jr . Boulevard

Gretchen Washington, Supervisor Lynwood, California 90262




All County Letter MSSP Contact Names

Orange' - contract ends 6130103.

Partners in Care" - covers the WattsISouth Central LA area under a distinct wntracUoffice effective 4101103



Stale of WilanbUealth end Hmml Agency

MEDI-CAL NOTICE OF ACTION

APPROVAL OF BENEFITS MULTIPURPOSE SENIOR SERVICES

PROGRAM WAIVER L ( C O W STAMP)

Notice date: Case numbec Worker name: Wwker number: Worker telephone number: Office hours: Notice lor:

The California Department of Aging's Medi-Cal Multipurpose Senior Services Program (MSSP) waiver provides extra services to persons 65 years of age or more who meet the MSSP requirements and who qualify for Medi-Cal under special deeming rules when they live with a spouse.

0 You are entitled to full Medi-Cal benefits including case management services with no monthly cost beginning

0 You are entitled to full Medi-Cal benefits including case management services beginning . Your monthly share-ofcost is $

In order to remain eligible for this program, you must:

Report changes, such as your income, health insurance, living situation, medica condition, property, or your address within 10 days.

Continue to meet the Department of Aging rules for this waiver.

Provide any requested information.

If you do not have a plastic Benefits Identification Card (BIC), you will receive one so( . Always show your BIC to your medical provider whenever you need care. This card is good as , ,lg as you are eligible for Medi-Cal. DO NOT THROW AWAY YOUR PLASTIC BIC.

The statute that requires this action is Section 51 346, Title 22, California Code of Regulatio.:~.

cc: Department of Aging

-- -- -- -



Stated Cdilaib-HeWh and Hunan Wcet Agency ~eparvnenl d Health Services Mdi-W Pqrarn

NOTIFICACION DE ACCION r 1 DE MEDI-CAL

APROBACION DE BENEFlClOS DE SERVICIOS DE EXTENSION PARA EL PROGRAMA

DE SERVICIOS CON PROP~SITO M~~LTIPLE PARA LAS PERSONAS DE LA TERCERA EDAD L

(COUNM STAMP) J

Fecha de la notificaabn: Ntirnero del caso: Nornbre del trabajadw: Nurnero del trabajador: Nurnero de tel6fono del trabajador:

J Horas hAbiles: Notilicad6n para:

Los Servicios de Extension para el Programa de Medi-Cal de Servicios con Proposito M~jltiple para las Personas de la Tercera Edad (Medi-Cal Multipurpose Senior Services Program-MSSP) del Departamento para las Personas de la Tercera Edad de California, proporciona servicios adicionales para las personas de 65 aiios de edad, o mayores, quienes cumplan con 10s requisitos del MSSF: y reunan 10s requisitos para recibir beneficios de Medi-Cal, bajo las reglas de consideracibn especial, cuando vivan con un(a) conyuge.

0 Usted tiene derecho a recibir beneficios cornpletos de Medi-Cal, incluyendo 10s servicios de administracion del caso, sin costo mensual, a partir del

0 Usted tiene derecho a recibir beneficios cornpletos de Medi-Cal, incluyendo 10s servicios de administracion del caso, a partir del . Su parte del costo mensual es de $

Para continuar reuniendo 10s requisitos para este programa, usted tiene que:

Reportar, en un plazo de 10 dias, cualquier cambio, como por ejemplo, en sus ingresos, seguro medico, situacion en el hogar, condicion medica, propiedad o su direccion. . Continuar cumpliendo con las reglas para estos servicios de exfensibn, establezidas por el Departamento para las Personas de la Tercera Edad. . Proporcionar cualquier inforrnacion solicitada.

Si usted no tiene una Tarjeta de Identificacibn de Beneficios de plastic0 (Benefits I entification CarGBIC), pronto recibira una. Siempre presente su BIC a su proveedor medico, crda vez que necesite atencion. Esta tarjeta es valida, mientras usted reuna 10s requisitos para reci! Ir beneficios de Medi-Cal. NO TIRE SU TARJETA BtC DE P~STICO.

El estatuto que requiere esta accion se establece en la Seccion 51346, del Titulo 22, del Codigo de Regulaciones de California.

cc: Departamento para las Personas de la Tercera Edad

-



Sgte o(CSiani8--He& and Hum= Swvices Ageocy C€$@mmdHeaMlService, MedCCal Program

MEDI-CAL NOTICE OF ACTION

r 7 DENIAL OR DISCONTINUANCE OF BENEFITS

MULTIPURPOSE SENIOR SERVICES PROGRAM WAIVER L

(COUNTY STAMP) _I

1 Notice date: Case numbec Worker name: Worker number: Worker telephone number:

_I Office hours: Notice lor:

The California Department of Aging's Medi-Cal Multipurpose Senior Services Program (MSSP) Waiver provides extra services to persons 65 years of age or more who meet the MSSP requirements and who qualify for Medi-Cal under special deeming rules when they live with a spouse.




0 Your property is over the limit of

0 The Department of Aging has informed us that you are no longer eligible for waiver services.

0 You are no longer living in the home with your spouse.

0 Other:

DO NOT THROW AWAY YOUR PLASTIC BENEFITS IDENTIFICATION CARD (BIC). You can use it again if you become eligible or are eligible for another Medi-Cal program.

The statute that requires this action is Section 51 346, Title 22, California Code of Regulations.

cc: Department of Aging

MC RRR I 1 7 M I



Sla(ed Cddms-Hem and Human S e m t e Agm Departmen1 d Healln SeMces Me-&! Prqram

NOTIFICAC~ON DE ACCION DE MEDI-CAL r 7

N E G A C ~ ~ N 0 SUSPENS~ON DE BENEFlClOS DE SERVlClOS DE EXTENSI~N PARA EL PROGRAMA

DE SERVlClOS DE PROP~SITO M~~LTIPLE PARA LAS PERSONAS DE LA TERCERA EDAD L

(COUNTY STAMP) _J

7 Fecha de la notilcac~on: Nljrnero del caso: Nornbre del trabajador: Nurnero del trabajador: Nurnero de telbfono del trabajador:

A Horas hbbiles: Notificacih para:

Los Servicios de Extension para el Programa de Medi-Cal de Servicios con Proposito Multiple para las Personas de la Tercera Edad (Medi-Cal Multipurpose Senior Services Program-MSSP) del Departamento para las Personas de la Tercera Edad de California, proporciona servicios adicionales para las personas de 65 afios de edad, o mayores, quienes cumplan con 10s requisitos del MSSt? y reunan 10s requisitos para recibir beneficios de Medi-Cal, bajo las reglas de consideracion especial, cuando vivan con un(a) conyuge.

0 Sus beneficios bajo este programa seran suspendidos, efectivo a partir del ultimo dia de

0 Su fecha de solicitud del ha sido denegada.

A continuacion se enumera(n) la(s) razon/razones del por que:

TJ Su propiedad sobrepasa el limite de

0 El Departamento para las Personas de la Tercera Edad nos ha informado que usted ya no reline 10s requisitos para 10s servicios de la extension.

0 Usted ya no esta viviendo en el hogar, con su conyuge.

0 Otro:

NO TIRE SU TARJETA DE IDENTIFICACI~N DE BENEFlClOS DE PLASTICO (BENEFITS lDENT/FlCATlON CARD-BIC). Usted puede volver a usarla, si llega a reunir 10s requisitos, o si r e h e 10s requisitos para otro programa de Medi-Cal.

El estatuto que requiere esta accion se establece en la Seccion 51346, del Titulo 22, del Codigo de Regulaciones de California.

cc: Departamento para las Personas de la Tercera Edad

MC 366 (SPI (rm2)

SECTION NO.: 51346 MANUAL LETTER NO.: 2 9 1 DATE: 09/03/04 190-56


state 01 Calmla-HeaRh and Human S- Agency

CALIFORNIA DEPARTMENT OF AGING (CDA) WAIVER REFERRAL

Department d Heanh Services Me%- P r v

Worker name Woiker number

Multipurpose Senior Services Program (MSSP) site: Please complete this portion and forward to the appropriate County Waiver contact person. Name of applicant

I Guardian (if applicable)

1

Address (number, street)

Social securrty number

Status

Sate Chy

Date ol birth

17 New Medi-Cal applicant.

ZIP code

Address of guardtan (if ddlerenl) (number, street)

CJ Currently receives Medi-Cal with a share-of-cost.

Telephone

C ~ Y Sate

Living Arrangement

ZIP code

CJ The applicant is currently in an institution. Please determine Medi-Cal eligibility based on hislher anticipated return to the community. Anticipated date of discharge:

0 The applicant is currently living in the home.

0 Other:

Eligibility Determination

If applicantlbeneficiary is living or will live at home with hislher spouse and is property eligible and entitled to zero share-of-cost Medi-Cal under regular eligibility rules, spousal impoverishment rules are not utilized. If the applicantlbeneficiary is property ineligible or has a share-of-cost, apply spousal impoverishment income and resource rules (i.e., institutional deeming rules) even if the applicantlbeneficiary lives in the home. See Article 19D of the Medi-Cal Eligibility Procedures Manual.

This is to certify that the individual named above has met the admission criteria for a nursing facility as defined in the California Code of Regulations, Title 2, Division 3, Subdivision 1, Chapter 3, Article 4, Sections 5 1334 and 51 335. Signature of MSSP sole contacl person

NOTE TO COUNTY: Please send a copy of the Notice of Action to the MSSP site when the deteminalion is compleled.

Printed name of MSSP site contact person

MSSP sne address (number, street)

White: County Copy MC 3M 112021

Yellow: MSSP Site Copy

Tnle

clv

SECTION NO.: 51346 MANUAL LETTER NO.: 2 9 1 DATE:09 /03 /04 19D-57

Telephone

( Sate

) ZIP code


State of California – Health and Human Services Agency Department of Health Care Services David Maxwell-Jolly, Director Medi-Cal Program

County Return Address NOTICE OF ACTION

APPROVAL OF ENROLLMENT IN ASSISTED LIVING WAIVER WITH MEDI-CAL CHANGES FOR BENEFICIARY

Notice date: ___________________________ Case number: _________________________ Worker name: _________________________ Worker number: _______________________ Worker telephone number: ______________ Office hours: __________________________ Notice for: ____________________

Medi-Cal Recipient Address Box

You have been approved for enrollment into the Assisted Living (AL) Waiver and your Medi-Cal coverage will change as described below. You are eligible for the AL Waiver and because special AL waiver rules were applied, you

are eligible for Medi-Cal without a share-of-cost beginning _________________.

Because you have a Community Spouse, special AL Waiver deeming rules apply.

Your Community Spouse Resource Allowance is $ _____________ and it is the maximum amount of property which your community spouse may keep in his/her own name. This amount is based upon the greatest of: the standard amount, an amount awarded by court order, or an amount awarded by a fair hearing. PLEASE NOTE: To remain eligible for Medi-Cal you must not have any excess property. You have until _________________ to transfer all of your net countable property, except for the $2,000 you are allowed to retain, into the name of the Community Spouse. After this date, you must have no more than $2,000 worth of net countable property held in your name.

Your spousal income allocation that you are allowed to give to your spouse is

SECTION NO.: 51346 MANUAL LETTER NO.: 307 DATE: 12/10/09 19D-57.1



$ ______________. If you decide not to give this amount to your spouse, you must tell your eligibility worker within 10 days. This may affect your eligibility or share-of-cost. If you or your spouse are dissatisfied with the calculation of the Community Spouse Resource Allowance, the determination of ownership or availability of property, or the spousal income allocation, either or both of you have the right to request a fair hearing. Any fair hearing on the calculation of the Community Spouse Resource Allowance must be held within 30 days from the date of the request for the hearing. See the reverse side of this notice for directions on how to request a fair hearing. The AL Waiver is limited to individuals eligible for Medi-Cal without a Medi-Cal share-of-cost who instead wish to live in a residential care provider site for the elderly or in publicly funded senior and/or disabled housing. Such individuals must have sufficient funds to pay for their board and room and care and supervision, with some funds remaining to meet personal and incidental needs. In determining Medi-Cal eligibility for individuals who are applying for enrollment into the AL Waiver, AL Waiver rules are used, including special AL waiver deeming rules for most married persons.

You do not have to fill out monthly or quarterly status reports for Medi-Cal. You must report to your Medi-Cal worker within 10 days if there are any changes in your

income, property, medical conditions, household situation, or living conditions.

You will have to complete a form for your Medi-Cal annual review. Always present your Benefits Identification Card (BIC) to your medical provider whenever you need care. This card is good for as long as you are eligible for Medi-Cal. DO NOT THROW AWAY YOUR BIC. This action is required by Welfare and Institutions Code Section 14132.26. If you have any questions, ask your worker. State Hearing: If you think this action is wrong, you can ask for a hearing. The back of this page tells you how. cc: AL Waiver liaison DHCS Monitoring and Oversight Section MC 240



MEDI-CAL NOTICE OF ACTION DENIAL OF ENROLLMENT IN ASSISTED LIVING WAIVER AND/OR MEDI-CAL

Notice date: ___________________________ Case number: _________________________ Worker name: _________________________ Worker number: _______________________ Worker telephone number: _______________ Office hours: __________________________

Medi-Cal Recipient Address Box :

County Return Address

Your request for enrollment into the Assisted Living (AL) Waiver has been denied. Here’s why.

You do not have sufficient funds to meet the costs of assisted living because you have a share-of-cost under regular Medi-Cal rules that is based on net countable income of $____________________. We then used special AL Waiver rules and found you still would have a share of cost. If

you are married with a community spouse, you were allowed a spousal income allocation of $ ________________ in this determination. Your net countable income and share-of-cost have been calculated as follows. You are not eligible for Medi-Cal even when we used special AL Waiver deeming rules

because your property exceeds the Medi-Cal limit of $ ______________. If you are married with a community spouse, you were allowed a Community Spouse Resource Allowance of $ _________________ that was based on the greatest of: the standard amount, an amount awarded by court order, or an amount awarded by a fair hearing. Your excess property was calculated as follows:

The net countable property held in the name of your community spouse:




ITEM VALUE

_____________________________________ ______________________ _____________________________________ ______________________ _____________________________________ ______________________

The net countable property held in your name:

ITEM VALUE

_____________________________________ ______________________

_____________________________________ ______________________

_____________________________________ ______________________

The net countable property held in both of your names: ITEM VALUE

_____________________________________ ______________________

_____________________________________ ______________________

_____________________________________ ______________________

Total net countable property ______________________

Minus your Community Spouse Resource - ______________________ Allowance. (This is the amount the community spouse may keep in his/her own name.)

Subtotal ______________________

Minus the property limit for one person (This is the amount you may keep in your own name.) - 2,000

Amount of excess property $ ________________ To be eligible for Medi-Cal you must not have any excess property by the last day of the month in which you apply for Medi-Cal benefits. You have $ _______________ worth of excess property and you are ineligible for Medi-Cal benefits unless you spenddown your excess property by the end of the month.



Other _______________________________________________________. If you or your spouse are dissatisfied with the calculation of the Community Spouse Resource Allowance, the determination of ownership or availability of property, or the spousal income allocation, either or both of you have the right to request a fair hearing. Any fair hearing on the calculation of the Community Spouse Resource Allowance must be held within 30 days from the date of the request for the hearing. See the reverse side of this notice for directions on how to request a fair hearing. IMPORTANT INFORMATION IF THIS NOTICE IS A DENIAL BECAUSE OF EXCESS PROPERTY AND YOU HAVE UNPAID MEDICAL BILLS: The MC 007 tells you about how this denial will be stopped if you use all of your excess property by paying medical bills that you owed during the month when you applied for Medi-Cal or after. This will not work if you wait more than three years. Ask your eligibility worker for an MC 007. The Assisted Living Waiver is limited to individuals eligible for Medi-Cal without a Medi-Cal share-of-cost who require nursing provider site A or B level of care but who instead wish to live in a residential care provider site for the elderly or in publicly funded senior and/or disabled housing. Such individuals must have sufficient funds to pay for their board and room and care and supervision, with some funds remaining to meet personal and incidental needs. In determining Medi-Cal eligibility of applicants who are applying for enrollment into the AL Waiver, AL waiver rules were used.

This action is required by Welfare and Institutions Code Section 14132.26.

If you have any questions, ask your worker. State Hearing: If you think this action is wrong, you can ask for a hearing. The back of this page tells you how. cc: AL WAIVER liaison DHCS Home and Community-Based Services Branch MC 242



MEDI-CAL NOTICE OF ACTION APPROVAL OF ENROLLMENT IN ASSISTED LIVING WAIVER AND INITIAL MEDI-CAL


Medi-Cal Recipient Address Box

Notice date: ___________________________ Case number: _________________________ Worker name: _________________________ Worker number: _______________________ Worker telephone number: _______________ Office hours: __________________________ Notice for: ________________________

County Return Address

You have been approved for enrollment into the Assisted Living (AL) Waiver and for Medi-Cal coverage as follows using AL waiver rules. You are eligible for the AL Waiver and for Medi-Cal beginning _____________________ .

Because you have a Community Spouse, special AL Waiver deeming rules apply.

Your Community Spouse Resource Allowance is $ _____________ and it is the maximum amount of property which your community spouse may keep in his/her own name. This amount is based upon the greatest of: the standard amount, an amount awarded by court order, or an amount awarded by a fair hearing. PLEASE NOTE: To remain eligible for Medi-Cal you must not have any excess property. You have until _________________ to transfer all of your net countable property, except for the $2,000 you are allowed to retain, into the name of the Community Spouse. After this date, you must have no more than $2,000 worth of net nonexempt property held in your name. Your spousal income allocation that you are allowed to give to your spouse is $ ______________. If you decide not to give this amount to your spouse, you must tell your eligibility worker within 10 days. This may affect your eligibility or share-of-cost. If you or your spouse are dissatisfied with the calculation of the Community Spouse Resource Allowance, the determination of ownership or availability of property, or the spousal income allocation, either or both of you have the right to request a fair hearing. Any fair hearing on the calculation of the Community Spouse Resource Allowance must be held within 30 days from the



date of the request for the hearing. See the reverse side of this notice for directions on how to request a fair hearing. The AL Waiver is limited to individuals eligible for Medi-Cal without a Medi-Cal share-of-cost who instead wish to live in a residential care provider site for the elderly or in publicly funded senior and/or disabled housing. Such individuals must have sufficient funds to pay for their board and room and care and supervision, with some funds remaining to meet personal and incidental needs. In determining Medi-Cal eligibility of applicants who are applying for enrollment into the AL Waiver, AL Waiver rules are used, including special deeming rules for most married persons. You do not have to fill out monthly or quarterly status reports for Medi-Cal. You must report to your Medi-Cal worker within 10 days if there are any changes in your

income, property, medical conditions, household situation, or living conditions. You will have to complete a form for your Medi-Cal annual review. Always present your Benefits Identification Card (BIC) to your medical provider whenever you need care. This card is good for as long as you are eligible for Medi-Cal. DO NOT THROW AWAY YOUR BIC. This action is required by Welfare and Institutions Code Section 14132.26. If you have any questions, ask your worker. State Hearing: If you think this action is wrong, you can ask for a hearing. The back of this page tells you how. cc: AL Waiver liaison DHCS Monitoring and Oversight Section MC 241



REFERRAL FORM FOR THE ASSISTED LIVING (AL) WAIVER Date: ___________ To: ______________________________ ( AL Waiver contact) __________________ County Phone Number From: _______________________________ Department of Care Health Services Monitoring and Oversight Section. Phone: _______________________________ e mail: _________________________ Fax___________________________ This notice concerns the individual named below. Individual: ____________________________________ Case Name: ___________________________ Address: _____________________________________ City/State: _____________________________ Zip Code: ____________________________________ Social Security Number: ____________________ Date of Birth: ______________________ Telephone Number: ______________________ This individual □ has been screened as medically eligible for the AL Waiver , □ will be disenrolled from the AL Waiver as of ______________________. County Instructions: This individual is already eligible for no-cost Medi-Cal, no new determination is needed, and this form

does not need to be returned to the Monitoring and Oversight Section. This referral form is to inform the county that this individual is already or will be moving to assisted living on ________________. Please determine Medi-Cal eligibility for the above individual and then e mail or fax this form to:

Results of county determination:

If the above individual is enrolled in the AL Waiver, he/she will be eligible for Medi-Cal with no share-of-cost a Medi-Cal share-of-cost of $ ___________________________.

Special AL Waiver rules were used in this determination: □ Yes □ No



Net nonexempt income was calculated as follows: The above individual is ineligible for Medi-Cal even when AL Waiver rules are applied because _________________________________________________________________. County Instructions Once This Form is Returned by DHCS: DHCS will be enrolling the above individual in the AL Waiver effective

___________________________. Please report his/her Medi-Cal eligibility to MEDS beginning with this month and also report any 3-month retroactive eligibility using regular Medi-Cal rules.

DHCS will not be enrolling the above individual in the AL Waiver because

he/she has a share of cost under regular Medi-Cal and would have a share of cost even if enrolled in the AL waiver.

other: ___________________________________ DHCS will be disenrolling the above individual from the AL Waiver because

_________________________________________________. Please redetermine his/her Medi-Cal eligibility without using AL Waiver rules. Note: This individual may have a change in his/her living arrangement.

MEDI-CAL ELIGIBILITY PROCEDURES MANUAL - - -

COUNTY WAIVER CONTACTS March 2004

CONTACT COUNTY

Joyce Cooper Social Services Agency 1 1 06 Madison Street, Suite 307 Oakland, CA 9461 2 (510) 267-9442 (510) 267-9428 FAX

Regina Britschgi Health and Human Services 75-A Diamond Valley Road Markleeville, CA 96120 (530) 694-2235 (530) 694-2252 FAX

Kim Crippen Department of Social Services 1003 Broadway Jackson, CA 95642 (209) 223-6569 (209) 223-6208 FAX

Gigi Gilbert Department of Social Welfare 42 County Center Drive P.O. Box 1649 Oroville, CA 94965 (530) 538-5149 (530) 538-691 8 FAX

Connie McLain Department of Social Welfare 891 Mountain Ranch Road San Andreas, CA 95249 (209) 754-6444 (209) 754-6566 FAX

Nancy Montgomery Department of Health

and Human Services Colusa, CA 95932 (91 6) 458-4985 (916) 458-5771 FAX

Alameda

Alpine

Butte

Calaveras

Colusa




CONTACT COUNTY

Sandy Baldwin Contra Costa Medi-Cal Program Analyst Employment and Human Services Department 40 Douglas Drive Martinez. CA 94553 (925) 313-1621 (925) 313-1758 FAX email: [email protected]

Carmen Chavez Del Norte Department of Health and Social Services 880 Northwest Drive Crescent City, CA 95531 (707) 464-3191 (707) 465-1 783 FAX

Midge Mortensen Department of Social Services 3057 Briw Road Placerville, CA 95684 (530) 642-71 59 (530) 626-9060 FAX

Karen Sebilian Department of Employment and

Temporary Assistance 4449 East Kings Canyon Fresno, CA 93750-0001 (559) 253-91 77 . (559) 253-9250 FAX

Becky Hansen Human Resources P.O. Box 61 1 Willows, CA 95988 (530) 934-6514 (530) 934-6521 FAX

Mary McCutcheon Department of Social Services 929 Koster Street Eureka, CA 95501 (707) 268-2785

Dora Juslin Department of Social Services 2995 South 4th Street, Suite 105 El Centro, CA 92243 (760) 337-6800 (760) 337-5716 FAX

El Dorado

Fresno

Glenn

Hum boldt

Imperial

SECTION NO.: 51346 MANUAL LETTER NO.: 2 9 1 DATE: 0 9 / 0 3 / 0 4 19D-59



CONTACT COUNTY

Candy Ross Health and Human Services 914 North Main Street Bishop, CA 93514 (760) 872-1 394

Barbara Gause or Donna Dunkin Department of Human Services P.O. Box 51 1 Bakersfield, CA 93302 (661) 631-6094 (661) 633-7047 FAX

Aida Guzman Human Services Agency 1200 South Drive Hanford, CA 93230 (559) 582-3241 EXT. 4793 FAX 584-2749

Beverly Mangue Department of Social Services 15975 Anderson Ranch Parkway P.O. Box 9000 Lower Lake. CA 95457 (707) 995-4262 (707) 995-4204 FAX

Mary Polley Welfare Department P.O. Box 1359 Susanville, CA 96130 (530) 251-8148

Rene Lima Department of Public Social Services 12900 Crossroads Parkway South City of Industry, CA 91 745 (562) 908-3529 (562) 908-0593 FAX

Candy Lopez Department of Public Welfare Madera County P.O. Box 569 Madera, CA 93639 (559) 675-2364 (559) 675-7693 FAX

lnyo

Kern

Kings

Lake

Lassen .

Los Angeles

Madera

- 3 -

- -

SECTION NO.: 51346 MANUAL LETTER NO.: 291 DATE:og/03/04 19D-60

. . - - -. . . - - - - . . . . - . . - . -

MEDI-CAL ELlGlBlLlN PROCEDURES MANUAL

. .


CONTACT COUNTY

Pat McCormack Department of Health

and Human Services P.O. Box 4160 120 N Redwood Drive, Rm 316 San Rafael, CA 9491 3 (41 5) 473-3547 (41 5) 473-3556 FAX

Becky Bradshaw Department of Social Services P.O. Box 7 Mariposa, CA 95338 (209) 966-3609 (209) 966-5943 FAX

Nancy Naumann Department of Social Services P.O. Box 1060 Ukiah, CA 95482 (707) 463-7828 (707) 463-7859 FAX

Mary Ellen Arana Human Services Agency 21 15 West Wardrobe Avenue Merced, CA 95341-001 (209) 385-3000 EXT. 5488 (209) 725-3583 FAX

Pat Wood Department of Social Services 120 North Main Street Alturas, CA 96101 (530) 233-6501

Julie Timerman Department of Social Services P.O. Box 2969 Mammoth Lakes, CA 93546 (760) 934-351 1 (760) 924-5431 FAX

Mariposa

Mendocino

Merced

Modoc

Mono

Yvette Grimes Monterey Department of Social Services 1000 South Main Street, Suite 208 Salinas, CA 93901 (831) 755-4407 (831) 755-8408 FAX

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CONTACT COUNTY

Darlene Washbum Health and Human Services 2261 Elm Street Napa, CA 94559-3721 (707) 253-4468

Cindy Lackey Human Services Agency P.O. Box 1210 Nevada City, CA 95959 (530) 265-1 379 (530) 265-7062 FAX

Maria Hernandez Social Services Agency 888 North Main Street, Suite 158C Santa Ana, CA 92701 (714) 541-7805 (71 4) 245-61 88 FAX

Laurie Rodman Welfare Department 100 Stonehouse Court Roseville, CA 95678 (916) 784-6079 (91 6) 784-61 00 FAX

Virgina Ekonen Department of Social Services P.O. Box 360 Quincy, CA 95971 (530) 283-6441 (530) 283-6368 FAX

Sue de Jonckheere Department of Public Social Services 1605 S p ~ c e Street Riverside, CA 92507 (909) 358-3992 (909) 358-3990 FAX

Jennifer SipelFred Tam Department of Social Services 2433 Marconi Avenue Sacramento, CA 95821 (916) 875-3731 (916) 875-3591 FAX

Alma Villasana Human Services Agency 11 11 San Felipe Road, Suite 206 Hollister, CA 95023 (831) 636-4180

Napa

Nevada

Orange

Placer

Plurnas

Riverside

Sacramento

San Benito




CONTACT COUNTY

Candice Karpinen San Bernardino Department of Public Social Services 150 South Lena Road San Bernardino, CA 9241 5-051 5 (909) 388-0280 (909) 338-0281 FAX

Suzette St. Pierre San Diego Department of Health and Human Services 8840 Complex Drive, Suite 255 San Diego, CA 92123-1423 (858) 565-5029 (858) 565-31 83 FAX

Mary Adrian San Francisco Department of Human Services P.O. Box 7988 San Francisco, CA 94120 (415) 558-1951 (415) 558-1841 FAX

Diane Luis Human Services Agency P.O. Box 201056 Stockton, CA 95202 (209) 468-1 153 (209) 468-1 985 FAX

Christina Chow Department of Social Services 3433 South Higuera Street P.O. Box 81 19 San Luis Obispo, CA 93403-81 19 (805) 781-1897 (805) 781 -1 846 FAX

Lorena Gonzalez Department of Social Services 400 Harbor Boulevard, Building C Belmont, CA 94002 (605) 595-7570 (605) 595-7576 FAX

Mysty Bonner Department of Social Services 1 100 West Laurel Lompoc, CA 93436 (805) 737-7056

Janette Anastacio Department of Social Services 333 West Julian Street, 5' Floor San Jose, CA 951 10-2335 (408) 491 -6700 (408) 975-4530 FAX

San Joaquin

San Luis Obispo

San Mateo

Santa Barbara

Santa Clara

SECTION NO.: 51346 MANUAL LETTER NO.: 2 g 1 DATE: 09/03/04 19D-63



CONTACT COUNTY

Nan Toy Human Resources Agency P.O. Box 1320 Santa Cruz, CA 95061 (408) 454-41 42 (408) 454-4092 FAX

Janet Wright Department of Social Services P.O. Box 6005 Redding, CA 96099-6005 (91 6) 245-6464 (91 6) 225-5087 FAX

Lori Wright Human Services P.O. Box 1019 Loyalton. CA 961 18 (530) 993-6725 (530) 993-6767 FAX

Collette Thornton Human Services Department 818 South Main Street Yreka, CA 96097 (530) 841-2708 (530) 841 -2791 FAX

Santa Cruz

Shasta

Sierra

Siskiyou

Diana Perez Health and Social Services 275 Beck Ave MS 5-130 P.O.Box 5050 Fairfield, CA 94533-6804 (707) 784-871 5 (707) 432-3548 FAX [email protected]

Kim Seamans Sonoma Human Services Department 2550 Paulin Drive P.O. Box 1539 Santa Rosa, CA 95402 (707) 565-5304 (707) 565-5353 FAX

Mary Michael Department of Social Services P.O. Box 42 Modesto, CA 95353-0042 (209) 558-2525 (209) 558-21 89 FAX

Stanislaus

-

SECTION NO.: 51346 MANUAL LETTER NO.: 2 9 1 DATE: 09/03/04 191)-64

. . . . . . - . - . . .



CONTACT COUNTY

Denise Damm Department of Welfare

and Social Services P.O. Box 1535 Yuba City, CA 95992-1 535 (530) 882-7230 EXT. 218 (530) 882-721 2 FAX

Bobbie Stillwell Department of Social Services P.O. Box 1515 Red Bluff, CA 96080 (530) 528-4081 (530) 528-5410 FAX

Marilyn Blackburn Department of Health

and Human Services P.O. Box 1470 Weaverville, CA 96093 (530) 623-1 265 (530) 623-1250 FAX

Kathy Johnstone Health and Human Services Agency P.O. Box 5059 Visalia, CA 93278 (559) 685-481 5 EXT. 246 (559) 685-4824 FAX

Rebecca Espino Department of Social Services 20075 Cedar Road North Sonora, CA 95370 (209) 533-5746 (209) 533-5714 FAX

Cecilia Taylor Human Services Agency 505 Poli Street Ventura, CA 93001 (805) 652-7522 (805) 652-7845 FAX

Monica Perez Department of Social Services 120 West Main Street Woodland, CA 95695 (530) 661-2806 (530) 661 -2847 FAX

Robert Guerin Department of Social Services P.O. Box 2320 Marysville, CA 95901 (530) 749-6452 (530) 749-6281 FAX

Sutter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yuba


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